Provider Demographics
NPI:1497528426
Name:GAUTHIER, STEPHANIE A (LPC-IT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:A
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 MICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7638
Mailing Address - Country:US
Mailing Address - Phone:262-309-5521
Mailing Address - Fax:
Practice Address - Street 1:3800 N MAYFAIR RD # 1
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2213
Practice Address - Country:US
Practice Address - Phone:262-536-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7671-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional