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General NPI Number Information
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NPI Number | 1043622780
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Entity Type | Organization
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Legal Business Name | GATEWAY PEDIATRIC THERAPY LLC
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 32100 TELEGRAPH RD SUITE 185
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City | BINGHAM FARMS
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State | MI
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Zip | 48025-2452
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Country | US
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Telephone | 248-494-2524
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Fax |
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Provider Business Mailing Address
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Address Line | 32100 TELEGRAPH RD SUITE 185
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City | BINGHAM FARMS
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State | MI
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Zip | 48025-2452
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Country | US
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Telephone | 248-494-2524
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Fax |
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Authorized Official
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Title or Position | THERAPIST / OWNER
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Name | CHRISTINA JEAN VESTEVICH
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Credential | BCBA
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Telephone | 248-509-4537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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