Healthcare Provider Details

I. General information

NPI: 1528366424
Provider Name (Legal Business Name): GATEWAY COUNSELING INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N 3RD AVE STE 330
POCATELLO ID
83201-6331
US

IV. Provider business mailing address

151 N 3RD AVE STE 330
POCATELLO ID
83201-6331
US

V. Phone/Fax

Practice location:
  • Phone: 208-242-3771
  • Fax: 208-242-3772
Mailing address:
  • Phone: 208-242-3771
  • Fax: 208-242-3772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: COREY LYNN RICHARDSON
Title or Position: OWNER
Credential: LCSW
Phone: 208-242-3771