Provider Demographics
NPI:1871185223
Name:GATES, ELEANOR
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:GATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 W OLD SHAKOPEE RD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2654
Mailing Address - Country:US
Mailing Address - Phone:612-261-1503
Mailing Address - Fax:
Practice Address - Street 1:6300 W OLD SHAKOPEE RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55438-2654
Practice Address - Country:US
Practice Address - Phone:612-261-1503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1588993091Medicaid