Basic Information
| Provider Information | |||||||||
| NPI: | 1629387196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | CHASITY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | EDS, LMFT INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1547 PARKWAY | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642297120 | ||||||||
| FaxNumber: | 8642295526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1547 PARKWAY | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296464081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642297120 | ||||||||
| FaxNumber: | 8642295526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2010 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4538 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 421504 | 05 | SC | MEDICAID |