Provider Demographics
NPI:1467208389
Name:GATEWAY PROFESSIONAL SERVICES, PC
Entity type:Organization
Organization Name:GATEWAY PROFESSIONAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-663-1130
Mailing Address - Street 1:55 E JACKSON BLVD STE 1500
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-4184
Mailing Address - Country:US
Mailing Address - Phone:312-663-1130
Mailing Address - Fax:312-663-0504
Practice Address - Street 1:4812 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5969
Practice Address - Country:US
Practice Address - Phone:877-381-6538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty