Provider Demographics
NPI:1962089425
Name:GATEWAY PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:GATEWAY PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TATAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-712-4266
Mailing Address - Street 1:32100 TELEGRAPH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2454
Mailing Address - Country:US
Mailing Address - Phone:248-712-4266
Mailing Address - Fax:248-712-4381
Practice Address - Street 1:32100 TELEGRAPH RD STE 205
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2454
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:248-712-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty