Provider Demographics
NPI:1013083575
Name:GAUTHIER, EVELYN CAROLE (LMSW)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:CAROLE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:BROYLES, BLOSE, BONDY, DASCHKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:46484 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5365
Mailing Address - Country:US
Mailing Address - Phone:586-770-1189
Mailing Address - Fax:
Practice Address - Street 1:35455 GARFIELD RD
Practice Address - Street 2:#C
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2236
Practice Address - Country:US
Practice Address - Phone:586-792-5335
Practice Address - Fax:586-792-3061
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010827431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ26426270Medicare ID - Type Unspecified