=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992834550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY BEHAVIORAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 10/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E 15TH ST
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31569-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-576-5075
-----------------------------------------------------
Fax | 912-576-3543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 COASTAL VILLAGE DR
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-1974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-554-8510
-----------------------------------------------------
Fax | 912-264-5965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DR. WILLIAM PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-554-8464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------