Provider Demographics
NPI:1477268951
Name:GAUDETTE, EMILY ROSE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:GAUDETTE
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 1:15 PADDOCK LN
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-4277
Mailing Address - Country:US
Mailing Address - Phone:978-815-6514
Mailing Address - Fax:
Practice Address - Street 1:15 PADDOCK LN
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-4277
Practice Address - Country:US
Practice Address - Phone:978-815-6514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE