Provider Demographics
NPI:1992834550
Name:GATEWAY BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:GATEWAY BEHAVIORAL HEALTH SERVICES
Other - Org Name:GATEWAY BHS - TC NOW
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-554-8464
Mailing Address - Street 1:700 COASTAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1974
Mailing Address - Country:US
Mailing Address - Phone:912-554-8510
Mailing Address - Fax:912-264-5965
Practice Address - Street 1:210 E 15TH ST
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-5501
Practice Address - Country:US
Practice Address - Phone:912-576-5075
Practice Address - Fax:912-576-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000622553CMedicaid