Healthcare Provider Details

I. General information

NPI: 1831508522
Provider Name (Legal Business Name): GATEWAY DETROIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11457 SHOEMAKER ST
DETROIT MI
48213-3418
US

IV. Provider business mailing address

11457 SHOEMAKER ST
DETROIT MI
48213-3418
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax: 313-924-0609
Mailing address:
  • Phone: 313-331-3435
  • Fax: 313-924-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number6803086187
License Number StateMI

VIII. Authorized Official

Name: FREDERICK CARR
Title or Position: SOCIAL WORKER/CASE MANAGER
Credential: B.S.,S.S.T
Phone: 313-331-3435