Healthcare Provider Details

I. General information

NPI: 1851740559
Provider Name (Legal Business Name): GATEWAY FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 10/21/2016
Certification Date:
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 SUITE 1500
CHICAGO IL
60604-4466
US

V. Phone/Fax

Practice location:
  • Phone: 877-505-4673
  • Fax: 217-529-9151
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number05380051
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS P BRITTON
Title or Position: PRESIDENT/CEO
Credential: DRPH,LPC,LCAS, CCS
Phone: 312-663-1130