Healthcare Provider Details

I. General information

NPI: 1427425859
Provider Name (Legal Business Name): GATEWAY ACADEMY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2487 S 700 E
SALT LAKE CITY UT
84106-1722
US

IV. Provider business mailing address

2487 S 700 E
SALT LAKE CITY UT
84106-1722
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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number3132
License Number StateUT

VIII. Authorized Official

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