Healthcare Provider Details

I. General information

NPI: 1598914095
Provider Name (Legal Business Name): GATEWAY FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 E PARK ST
CARBONDALE IL
62901-3812
US

IV. Provider business mailing address

55 E JACKSON BLVD SUITE 1500
CHICAGO IL
60604-4466
US

V. Phone/Fax

Practice location:
  • Phone: 877-505-4673
  • Fax: 618-549-9540
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberA-0538-0003-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberA-0538-0003-A
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA-0538-0003-A
License Number StateIL

VIII. Authorized Official

Name: RENEE ENNIS MCGEE
Title or Position: MANAGER
Credential:
Phone: 678-445-4833