Healthcare Provider Details

I. General information

NPI: 1255703971
Provider Name (Legal Business Name): MICHELLE C GATES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOLMES ST
KANSAS CITY MO
64108-2640
US

IV. Provider business mailing address

315 W CARPENTER ST PO BOX 19677
SPRINGFIELD IL
62702-4901
US

V. Phone/Fax

Practice location:
  • Phone: 816-404-4375
  • Fax: 816-404-4337
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2018000612
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071-009144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: