Healthcare Provider Details

I. General information

NPI: 1033690003
Provider Name (Legal Business Name): LUCAS D GAUTHIER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 MARINETTE AVE
MARINETTE WI
54143-3801
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE STE 113
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 715-735-5500
  • Fax: 715-735-5502
Mailing address:
  • Phone: 920-560-1083
  • Fax: 920-560-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14425-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: