Healthcare Provider Details

I. General information

NPI: 1598367880
Provider Name (Legal Business Name): GATEWAY BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 MANTON WAY
LANHAM MD
20706-2487
US

IV. Provider business mailing address

6500 MANTON WAY
LANHAM MD
20706-2487
US

V. Phone/Fax

Practice location:
  • Phone: 240-505-5427
  • Fax:
Mailing address:
  • Phone: 240-505-5427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRACE DOH
Title or Position: PRESIDENT
Credential: PMHNP
Phone: 240-505-5427