Basic Information
| Provider Information | |||||||||
| NPI: | 1750583001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAYS HOSPITAL AND MENTAL HEALTH CENTER | ||||||||
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| OtherOrganizationName: | GATEWAYS PERCY VILLAGE OP CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1891 EFFIE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900261711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236442000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4063 WHITTIER BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900232536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | PHIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3236442000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GATEWAY HOSPITAL & MENTAL HEALTH CENTER | ||||||||
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| AuthorizedOfficialCredential: | PSY.D | ||||||||
| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 198600612 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.