Healthcare Provider Details

I. General information

NPI: 1124794532
Provider Name (Legal Business Name): BRIAN JOHN GAUTHIER RAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19344 N 10TH ST
COVINGTON LA
70433-8877
US

IV. Provider business mailing address

2235 POYDRAS ST
NEW ORLEANS LA
70119-7561
US

V. Phone/Fax

Practice location:
  • Phone: 985-276-4165
  • Fax:
Mailing address:
  • Phone: 504-524-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRAC-5088
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: