Provider Demographics
NPI:1760732556
Name:GAUTHIER, JERROD A (LMT)
Entity Type:Individual
Prefix:
First Name:JERROD
Middle Name:A
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WESTMINSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-4620
Mailing Address - Country:US
Mailing Address - Phone:813-326-0404
Mailing Address - Fax:
Practice Address - Street 1:3135 STATE ROAD 580
Practice Address - Street 2:SUITE 11
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-4976
Practice Address - Country:US
Practice Address - Phone:813-326-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA44066225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist