Provider Demographics
NPI:1053083899
Name:GAUTHIER, RICHARD E (LSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4237 CORAL BERRY PATH APT 306
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9320
Mailing Address - Country:US
Mailing Address - Phone:312-912-1860
Mailing Address - Fax:
Practice Address - Street 1:1190 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7960
Practice Address - Country:US
Practice Address - Phone:847-549-2235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105130104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker