Provider Demographics
NPI:1104997279
Name:GAUTHIER, DAVID (MA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1338
Mailing Address - Country:US
Mailing Address - Phone:802-655-3311
Mailing Address - Fax:
Practice Address - Street 1:432 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1338
Practice Address - Country:US
Practice Address - Phone:802-655-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006777Medicaid
VT9993OtherBCBS