Healthcare Provider Details

I. General information

NPI: 1568164341
Provider Name (Legal Business Name): GATEWAY PROFESSIONAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N HERSHEY RD STE B
BLOOMINGTON IL
61704-3560
US

IV. Provider business mailing address

55 E JACKSON BLVD
CHICAGO IL
60604-4466
US

V. Phone/Fax

Practice location:
  • Phone: 877-381-6538
  • Fax:
Mailing address:
  • Phone: 312-663-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY K KLEMANSKI
Title or Position: CEO
Credential:
Phone: 312-663-1130