Provider Demographics
NPI:1912271461
Name:GATEWAY BEHAHVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:GATEWAY BEHAHVIORAL HEALTH SERVICES
Other - Org Name:GLYNN PINEHAVEN GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-554-8498
Mailing Address - Street 1:727 PINE HAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-9567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 COASTAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1974
Practice Address - Country:US
Practice Address - Phone:912-554-8510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063-01-035-2320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000622553BIMedicaid