Provider Demographics
NPI:1023281987
Name:GATEWAY TO CHANGE
Entity type:Organization
Organization Name:GATEWAY TO CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECDUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:O
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:SAC IT
Authorized Official - Phone:414-442-2033
Mailing Address - Street 1:2319 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1919
Mailing Address - Country:US
Mailing Address - Phone:414-442-2033
Mailing Address - Fax:414-442-2167
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-442-2033
Practice Address - Fax:414-442-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2479251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42232700Medicaid
WI42232721Medicaid