Basic Information
| Provider Information | |||||||||
| NPI: | 1700285848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY DETROIT EAST COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3133313435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 6802087757 | MI | Y | Agencies | Case Management |
No ID Information.