MEDICARE: GATEWAY MENTAL WELLNESS

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1619472099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY MENTAL WELLNESS

Provider Business Mailing Address
First Line	:	709 PERRY ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2945
Country	:	US
Telephone Number	:	309-838-1888
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 DEER TRACKS TRL STE 260
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-1855
Country	:	US
Telephone Number	:	314-363-9385
Fax Number	:	314-394-1404

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MOLLY CHRISTINE THOMAS
Credential	:
Telephone Number	:	309-838-1888

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	03/27/2018

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Directions to “GATEWAY MENTAL WELLNESS ” Practice Location

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