Basic Information
| Provider Information | |||||||||
| NPI: | 1972074649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATES | ||||||||
| FirstName: | LATOYA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1029 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995591029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436800 | ||||||||
| FaxNumber: | 9075437101 | ||||||||
| Practice Location | |||||||||
| Address1: | 5016 NOEL POLTY BLVD | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995591029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436800 | ||||||||
| FaxNumber: | 9075437101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2018 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW130350 | PA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1006017 | 05 | AK | MEDICAID | 1584987 | 05 | AK | MEDICAID | 1020986 | 05 | AK | MEDICAID |