Provider Demographics
NPI:1992257240
Name:GATEWAY PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:GATEWAY PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSORY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:737-619-4477
Mailing Address - Street 1:11300 4TH ST N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-2918
Mailing Address - Country:US
Mailing Address - Phone:727-619-4477
Mailing Address - Fax:727-258-2348
Practice Address - Street 1:11300 4TH ST N
Practice Address - Street 2:SUITE 115
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-2918
Practice Address - Country:US
Practice Address - Phone:727-619-4477
Practice Address - Fax:727-258-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty