Healthcare Provider Details

I. General information

NPI: 1164027074
Provider Name (Legal Business Name): LISA GAUTHIER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LEAVITT RD
PITTSFIELD NH
03263-3203
US

IV. Provider business mailing address

14 LEAVITT RD
PITTSFIELD NH
03263-3203
US

V. Phone/Fax

Practice location:
  • Phone: 866-746-1184
  • Fax:
Mailing address:
  • Phone: 866-746-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2343
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: