Provider Demographics
NPI:1831508522
Name:GATEWAY DETROIT
Entity type:Organization
Organization Name:GATEWAY DETROIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:BS,SST
Authorized Official - Phone:313-331-3435
Mailing Address - Street 1:11457 SHOEMAKER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3418
Mailing Address - Country:US
Mailing Address - Phone:313-331-3435
Mailing Address - Fax:313-924-0609
Practice Address - Street 1:11457 SHOEMAKER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3418
Practice Address - Country:US
Practice Address - Phone:313-331-3435
Practice Address - Fax:313-924-0609
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086187305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization