Basic Information
| Provider Information | |||||||||
| NPI: | 1770958423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY TO SUCCESS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1748 | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812151748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195645070 | ||||||||
| FaxNumber: | 7198962874 | ||||||||
| Practice Location | |||||||||
| Address1: | 2429 S PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810052886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195645070 | ||||||||
| FaxNumber: | 7198962874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2015 | ||||||||
| LastUpdateDate: | 08/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | MORGENTHALER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7195645070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW, LAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 90000128872 | 05 | CO | MEDICAID |