Healthcare Provider Details

I. General information

NPI: 1447660089
Provider Name (Legal Business Name): GATEWAY JUVENILE DIVERSION PROJECT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 NORTH MAYSVILLE ST
MT STERLIG KY
40353
US

IV. Provider business mailing address

37 NORTH MAYSVILLE
MT STERLIG KY
40353
US

V. Phone/Fax

Practice location:
  • Phone: 859-498-9892
  • Fax: 859-498-0316
Mailing address:
  • Phone: 859-498-9892
  • Fax: 859-498-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENISE SPITTLER
Title or Position: CEO
Credential:
Phone: 859-498-9892