Provider Demographics
NPI:1528204534
Name:GAUTHIER, MCKENZIE NICHOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:NICHOLE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3224
Mailing Address - Country:US
Mailing Address - Phone:318-481-1043
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71306-9004
Practice Address - Country:US
Practice Address - Phone:318-466-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8318104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker