Healthcare Provider Details

I. General information

NPI: 1700285848
Provider Name (Legal Business Name): GATEWAY DETROIT EAST COMMUNITY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 MACK AVE
DETROIT MI
48207-2302
US

IV. Provider business mailing address

6309 MACK AVE
DETROIT MI
48207-2302
US

V. Phone/Fax

Practice location:
  • Phone: 313-921-4700
  • Fax:
Mailing address:
  • Phone: 313-921-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6802087757
License Number StateMI

VIII. Authorized Official

Name: MS. EVELYN THOMAS
Title or Position: CLINICAL DIRECTOR
Credential: LMSW
Phone: 313-331-3435