Basic Information
| Provider Information | |||||||||
| NPI: | 1508278458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51322 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421025622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707779283 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 W PROFESSIONAL PARK CT | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435300 | ||||||||
| FaxNumber: | 2708435383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | BECK | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING/CONTRACTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2707779283 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7100292870 | 05 | KY | MEDICAID |