Provider Demographics
NPI:1891028411
Name:GATEWAY PSYCHIATRIC GROUP, LLC
Entity Type:Organization
Organization Name:GATEWAY PSYCHIATRIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-567-1958
Mailing Address - Street 1:11710 OLD BALLAS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7076
Mailing Address - Country:US
Mailing Address - Phone:314-567-1958
Mailing Address - Fax:
Practice Address - Street 1:11710 OLD BALLAS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7076
Practice Address - Country:US
Practice Address - Phone:314-567-1958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health