Provider Demographics
NPI:1609184050
Name:GATEHOUSE THERAPEUTIC HEALTH SERVICES
Entity Type:Organization
Organization Name:GATEHOUSE THERAPEUTIC HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SOURS
Authorized Official - Suffix:
Authorized Official - Credentials:MC, LPC
Authorized Official - Phone:928-668-0710
Mailing Address - Street 1:159 W WICKENBURG WAY
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-2265
Mailing Address - Country:US
Mailing Address - Phone:928-668-0710
Mailing Address - Fax:928-684-6852
Practice Address - Street 1:159 W WICKENBURG WAY
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-2265
Practice Address - Country:US
Practice Address - Phone:928-668-0710
Practice Address - Fax:928-684-6852
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRANSITIONAL LIVING CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2644324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility