Healthcare Provider Details

I. General information

NPI: 1912813700
Provider Name (Legal Business Name): KELLEY LYNN GAUTHIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 N SHIAWASSEE ST
CORUNNA MI
48817-1151
US

IV. Provider business mailing address

13131 RIVER ROCK PASS
LINDEN MI
48451-8869
US

V. Phone/Fax

Practice location:
  • Phone: 989-743-3471
  • Fax:
Mailing address:
  • Phone: 989-743-3471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101001609
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: