Provider Demographics
NPI:1780776609
Name:GAUTHIER, CHRISTINA MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:MARIE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:PROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SOLVAY
Mailing Address - State:NY
Mailing Address - Zip Code:13209
Mailing Address - Country:US
Mailing Address - Phone:315-484-9447
Mailing Address - Fax:
Practice Address - Street 1:3328 WEST GENESSEE STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219
Practice Address - Country:US
Practice Address - Phone:315-484-9447
Practice Address - Fax:315-484-4583
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0110751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY435103OtherMVP
NYCC4456Medicare ID - Type Unspecified