Provider Demographics
NPI:1578588745
Name:GAUTHIER, MELISSA LEE (LCSW,MSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LCSW,MSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LEE
Other - Last Name:LAFOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW,MSW
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:906-776-9040
Practice Address - Fax:906-774-7279
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096507104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIML085216OtherBCBS OF MI