Provider Demographics
NPI:1730498254
Name:GAUTHIER, LYNETTE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6360
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-6360
Mailing Address - Country:US
Mailing Address - Phone:207-848-4000
Mailing Address - Fax:
Practice Address - Street 1:235 BILLINGS RD
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-0531
Practice Address - Country:US
Practice Address - Phone:207-848-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP788235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1073735676Medicaid