Healthcare Provider Details

I. General information

NPI: 1912196270
Provider Name (Legal Business Name): SHAWN L GAUTHIER LMSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CASCADE WEST PKWY SE
GRAND RAPIDS MI
49546-2137
US

IV. Provider business mailing address

550 CASCADE WEST PKWY SE
GRAND RAPIDS MI
49546-2137
US

V. Phone/Fax

Practice location:
  • Phone: 616-930-4123
  • Fax: 616-323-3994
Mailing address:
  • Phone: 616-930-4123
  • Fax: 616-323-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080903
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: