MEDICARE: MR. BRIAN JAY GAUTHIER LCSW, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	01496-L	NV
2	101YM0800X	Mental Health Counselor	7132-C	NV
3	1041C0700X	Clinical Social Worker	7132-C	NV
4	104100000X	Social Worker	7132-C	NV
5	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1346343209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN JAY GAUTHIER LCSW, LADC

Provider Business Mailing Address
First Line	:	7747 ASHBY GATE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-5111
Country	:	US
Telephone Number	:	760-272-5696
Fax Number	:

Provider Business Practice Location Address
First Line	:	7747 ASHBY GATE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-5111
Country	:	US
Telephone Number	:	760-272-5696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	05/26/2016

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