Provider Demographics
NPI:1790157097
Name:GATEWAY HAND THERAPY LLC
Entity Type:Organization
Organization Name:GATEWAY HAND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KLEIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L CHT CLT
Authorized Official - Phone:616-209-4429
Mailing Address - Street 1:3739 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9733
Mailing Address - Country:US
Mailing Address - Phone:616-209-4429
Mailing Address - Fax:616-432-2247
Practice Address - Street 1:3739 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9733
Practice Address - Country:US
Practice Address - Phone:616-209-4429
Practice Address - Fax:616-432-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001229225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G00491OtherBCBSM
MI1790157097Medicaid
MI0G00491OtherBCBSM
MI1790157097Medicaid
MI748169001Medicare PIN