Provider Demographics
NPI:1386233864
Name:GAUTHIER, KELLIE P (DC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:P
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7246 GARVIN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2828
Mailing Address - Country:US
Mailing Address - Phone:248-212-6916
Mailing Address - Fax:
Practice Address - Street 1:11837 MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1924
Practice Address - Country:US
Practice Address - Phone:734-421-0101
Practice Address - Fax:734-421-4895
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301011025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor