=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780127449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY NEUROPSYCHOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2016
-----------------------------------------------------
Last Update Date | 11/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 989 GARDENVIEW OFFICE PKWY
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-591-5564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 989 GARDENVIEW OFFICE PKWY
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-591-5564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. DAVID KAUFMAN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 314-591-5564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 2011028482
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------