Provider Demographics
NPI:1336479138
Name:SHAWN L. GAUTHIER
Entity Type:Organization
Organization Name:SHAWN L. GAUTHIER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-308-6423
Mailing Address - Street 1:1629 BLUE GRASS CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6217
Mailing Address - Country:US
Mailing Address - Phone:616-308-6423
Mailing Address - Fax:616-301-3508
Practice Address - Street 1:771 KENMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2370
Practice Address - Country:US
Practice Address - Phone:616-301-3479
Practice Address - Fax:616-301-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010809031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty