Healthcare Provider Details

I. General information

NPI: 1427726652
Provider Name (Legal Business Name): GATEWAY PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE STE 205F
ALBUQUERQUE NM
87110-6749
US

IV. Provider business mailing address

1330 SAN PEDRO DR NE STE 205F
ALBUQUERQUE NM
87110-6749
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-0936
  • Fax:
Mailing address:
  • Phone: 240-413-0936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL KPWE NJI
Title or Position: OWNER
Credential:
Phone: 240-413-0936