Healthcare Provider Details

I. General information

NPI: 1952659989
Provider Name (Legal Business Name): GATEWAY COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2012
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5506 PAYNE DR
KING GEORGE VA
22485-6213
US

IV. Provider business mailing address

PO BOX 149
DAHLGREN VA
22448-0149
US

V. Phone/Fax

Practice location:
  • Phone: 540-663-0574
  • Fax: 540-663-0576
Mailing address:
  • Phone: 540-663-0574
  • Fax: 540-663-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003741
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101050361
License Number StateVA

VIII. Authorized Official

Name: DR. KATHLEEN FITZSIMMONS
Title or Position: PRESIDENT
Credential: PSYD, LPC
Phone: 540-663-0574