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General NPI Number Information
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NPI Number | 1114749967
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Entity Type | Organization
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Legal Business Name | LIFE GATEWAY LLC
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Dates
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Enumeration Date | 10/31/2024
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 10467 MOUNT MITCHELL CT
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City | LAS VEGAS
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State | NV
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Zip | 89149-0907
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Country | US
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Telephone | 702-752-9274
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Fax |
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Provider Business Mailing Address
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Address Line | 10046 FLINK CREEK ST
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City | LAS VEGAS
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State | NV
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Zip | 89178-5566
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Country | US
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Telephone | 702-521-7495
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | STACY THORNTON
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Credential |
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Telephone | 702-521-7495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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