Provider Demographics
NPI:1255703971
Name:GATES, MICHELLE C
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
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 1:315 W CARPENTER ST
Mailing Address - Street 2:PO BOX 19677
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4901
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-0548
Practice Address - Street 1:2301 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2640
Practice Address - Country:US
Practice Address - Phone:816-404-4375
Practice Address - Fax:816-404-4337
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018000612103TC0700X
IL071-009144103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490050945Medicaid