Healthcare Provider Details

I. General information

NPI: 1346343209
Provider Name (Legal Business Name): BRIAN JAY GAUTHIER LCSW, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 ASHBY GATE ST
LAS VEGAS NV
89166-5111
US

IV. Provider business mailing address

7747 ASHBY GATE ST
LAS VEGAS NV
89166-5111
US

V. Phone/Fax

Practice location:
  • Phone: 760-272-5696
  • Fax:
Mailing address:
  • Phone: 760-272-5696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01496-L
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7132-C
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7132-C
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7132-C
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: