Provider Demographics
NPI:1952679458
Name:GATEWAY TO CHANGE
Entity Type:Organization
Organization Name:GATEWAY TO CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:QUIN
Authorized Official - Middle Name:O
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CSW,CSAC,CCS
Authorized Official - Phone:414-442-2033
Mailing Address - Street 1:2319 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1919
Mailing Address - Country:US
Mailing Address - Phone:414-442-2033
Mailing Address - Fax:
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-442-2033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI396006491261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center