Provider Demographics
NPI:1790262442
Name:GAUTHIER, DOLORES ANN (HIS)
Entity Type:Individual
Prefix:MS
First Name:DOLORES
Middle Name:ANN
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17495 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2059
Mailing Address - Country:US
Mailing Address - Phone:262-781-0226
Mailing Address - Fax:262-781-0271
Practice Address - Street 1:17495 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2059
Practice Address - Country:US
Practice Address - Phone:262-781-0226
Practice Address - Fax:262-781-0271
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI313-60OtherHEARING INSTRUMENT SPECIALIST LICENSE NUMBER