Healthcare Provider Details

I. General information

NPI: 1891028411
Provider Name (Legal Business Name): GATEWAY PSYCHIATRIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 OLD BALLAS RD SUITE 110
SAINT LOUIS MO
63141-7076
US

IV. Provider business mailing address

11710 OLD BALLAS RD SUITE 110
SAINT LOUIS MO
63141-7076
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-1958
  • Fax:
Mailing address:
  • Phone: 314-567-1958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEE BURLISON
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-567-1958