Healthcare Provider Details

I. General information

NPI: 1992834550
Provider Name (Legal Business Name): GATEWAY BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E 15TH ST
WOODBINE GA
31569-5501
US

IV. Provider business mailing address

700 COASTAL VILLAGE DR
BRUNSWICK GA
31520-1974
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-5075
  • Fax: 912-576-3543
Mailing address:
  • Phone: 912-554-8510
  • Fax: 912-264-5965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM PARKS
Title or Position: CFO
Credential:
Phone: 912-554-8464