Provider Demographics
NPI:1407408024
Name:GAUTHIER, ISABELLE
Entity Type:Individual
Prefix:
First Name:ISABELLE
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5-26 WILDE AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-5528
Mailing Address - Country:US
Mailing Address - Phone:484-574-9647
Mailing Address - Fax:
Practice Address - Street 1:5429 CHESTNUT ST STE G3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3325
Practice Address - Country:US
Practice Address - Phone:215-397-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000873106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist