Provider Demographics
NPI:1578295598
Name:GAUTHIER, REBECCA NICOLE FOLKESTADAS
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:NICOLE FOLKESTADAS
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 1:18812 CLARA MAE CT
Mailing Address - Street 2:
Mailing Address - City:ROUND HILL
Mailing Address - State:VA
Mailing Address - Zip Code:20141-2004
Mailing Address - Country:US
Mailing Address - Phone:571-528-2178
Mailing Address - Fax:
Practice Address - Street 1:22375 BRODERICK DR STE 125
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-9345
Practice Address - Country:US
Practice Address - Phone:571-375-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-22-222598106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician