Provider Demographics
NPI:1801367529
Name:GAUTHIER, STACY ANN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EAST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1900
Mailing Address - Country:US
Mailing Address - Phone:978-935-1390
Mailing Address - Fax:
Practice Address - Street 1:606 BROADWAY
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01832-1206
Practice Address - Country:US
Practice Address - Phone:978-935-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16030-MT-MT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist