Doctor Name: | MRS. KELLYE GAUTIER |
NPI Number: | 1104272616 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LAC, LAMFT |
License Number: | A1411154 |
Business Practice Address: | 2003 Se Walton Blvd Bentonville, AR - 727123725 |
Business Phone Number: | 4794260846 |
Business Fax Number: | |
Mailing Address: | 2003 Se Walton Blvd, BENTONVILLE |
State: | AR |
Postal Code: | 727123725 |
Phone Number: | 4794260846 |
Fax Number: | |
NPI Enumeration Date: | 05/13/2016 |
NPI Last Update Date: | 05/13/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | A1411154 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | AR |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |