Healthcare Provider Details

I. General information

NPI: 1336686310
Provider Name (Legal Business Name): CHRISTOPHER GAUTHIER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 CENTRAL AVE
EDGARD LA
70049-2531
US

IV. Provider business mailing address

177 CENTRAL AVE
EDGARD LA
70049-2531
US

V. Phone/Fax

Practice location:
  • Phone: 985-288-7688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number010154629
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: