Provider Demographics
NPI:1326518853
Name:GAUTHREAUX, JOHN CHARELS (BA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARELS
Last Name:GAUTHREAUX
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 VIKING DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2844
Mailing Address - Country:US
Mailing Address - Phone:916-262-8598
Mailing Address - Fax:
Practice Address - Street 1:3440 VIKING DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2844
Practice Address - Country:US
Practice Address - Phone:916-262-8598
Practice Address - Fax:916-262-8598
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201271041C0700X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical