Provider Demographics
NPI:1497085708
Name:GAUTHIER, SHANNON A (MA, LMHC, R-DMT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:A
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:MA, LMHC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1274
Mailing Address - Country:US
Mailing Address - Phone:978-679-1200
Mailing Address - Fax:978-486-4037
Practice Address - Street 1:119 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1274
Practice Address - Country:US
Practice Address - Phone:978-679-1200
Practice Address - Fax:978-486-4037
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7258OtherLICENSE MENTAL HEALTH COUNSELOR