Healthcare Provider Details

I. General information

NPI: 1891333977
Provider Name (Legal Business Name): GATEWAY PROFESSIONAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 STEVENSON DR
SPRINGFIELD IL
62703-4331
US

IV. Provider business mailing address

55 E JACKSON BLVD STE 1500
CHICAGO IL
60604-4184
US

V. Phone/Fax

Practice location:
  • Phone: 877-381-6538
  • Fax:
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROUEEN RAFEYAN
Title or Position: PRESIDENT
Credential:
Phone: 312-663-1130