Provider Demographics
NPI:1720456981
Name:GATEWAY ACADEMY, LLC
Entity Type:Organization
Organization Name:GATEWAY ACADEMY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BO
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-766-6604
Mailing Address - Street 1:941 E CATTAIL DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8583
Mailing Address - Country:US
Mailing Address - Phone:801-523-3479
Mailing Address - Fax:801-437-2984
Practice Address - Street 1:941 E CATTAIL DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8583
Practice Address - Country:US
Practice Address - Phone:801-523-3479
Practice Address - Fax:801-437-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
UT14178322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT95860OtherUT LICENSE