Provider Demographics
NPI:1790546653
Name:GAUTHIER, NICOLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1700
Practice Address - Fax:574-647-7572
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008723A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300087542Medicaid