Healthcare Provider Details

I. General information

NPI: 1801406145
Provider Name (Legal Business Name): GATEWAY FAMILY THERAPY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2020
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 EDISON
BENTON AR
72015-5359
US

IV. Provider business mailing address

400 EDISON
BENTON AR
72015-5359
US

V. Phone/Fax

Practice location:
  • Phone: 501-425-6476
  • Fax: 501-358-3095
Mailing address:
  • Phone: 501-425-6476
  • Fax: 501-358-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAQUITA SHANA WILLIS
Title or Position: CEO
Credential:
Phone: 501-425-6476