Healthcare Provider Details

I. General information

NPI: 1922348481
Provider Name (Legal Business Name): GATEWAY TO SUCCESS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

IV. Provider business mailing address

PO BOX 1748
CANON CITY CO
81215-1748
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-5070
  • Fax: 719-896-2874
Mailing address:
  • Phone: 719-564-5070
  • Fax: 719-896-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number175401
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateCO

VIII. Authorized Official

Name: KAREN MORGENTHALER
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW, LAC
Phone: 719-564-5070