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NPI Code Detail

MEDICARE: GATEWAY TO CHANGE

MEDICARE: GATEWAY TO CHANGE
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
1261Q00000XClinic/Center396006491WI

General Provider Information

NPI Number : 1952679458
Entity Type Code : Organization
Provider Name (Legal Business Name) : GATEWAY TO CHANGE
Provider Business Mailing Address
First Line : 2319 W CAPITOL DR
Second Line :
City : MILWAUKEE
State : WI
Zip : 53206-1919
Country : US
Telephone Number : 414-442-2033
Fax Number :
Provider Business Practice Location Address
First Line : 2319 W CAPITOL DR
Second Line :
City : MILWAUKEE
State : WI
Zip : 53206-1919
Country : US
Telephone Number : 414-442-2033
Fax Number :
Authorized Official
Title or Position : CLINICAL SUPERVISOR
Name : MR. QUIN O GARRETT
Credential : MS,CSW,CSAC,CCS
Telephone Number : 414-442-2033
Provider Enumeration Date : 12/12/2011
Last Update Date : 12/12/2011

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Directions to “GATEWAY TO CHANGE ” Practice Location

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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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