Healthcare Provider Details

I. General information

NPI: 1720456981
Provider Name (Legal Business Name): GATEWAY ACADEMY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 E CATTAIL DR
DRAPER UT
84020-8583
US

IV. Provider business mailing address

941 E CATTAIL DR
DRAPER UT
84020-8583
US

V. Phone/Fax

Practice location:
  • Phone: 801-523-3479
  • Fax: 801-437-2984
Mailing address:
  • Phone: 801-523-3479
  • Fax: 801-437-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number14178
License Number StateUT

VIII. Authorized Official

Name: ANGIE EVANS
Title or Position: BO
Credential:
Phone: 801-766-6604