MEDICARE: GATEWAY PEDIATRIC THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	10547	NC

General Provider Information

NPI Number	:	1477910859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY PEDIATRIC THERAPY

Provider Business Mailing Address
First Line	:	1348 ILEAGNES RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-3436
Country	:	US
Telephone Number	:	407-619-7082
Fax Number	:	844-407-5282

Provider Business Practice Location Address
First Line	:	501 GATEWAY DR
Second Line	:	SUITE 101 E
City	:	CLAYTON
State	:	NC
Zip	:	27520-2277
Country	:	US
Telephone Number	:	919-578-8096
Fax Number	:	844-407-5282

Authorized Official
Title or Position	:	MANAGING PARTNER/SLP
Name	:	RANDI THOMAS
Credential	:	MA, CCC-SLP
Telephone Number	:	919-578-8096

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	01/15/2016

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Directions to “GATEWAY PEDIATRIC THERAPY ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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