Provider Demographics
NPI:1063053494
Name:GAUTHIER, ASHLEY M (LCSW)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:YUNGWIRTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:4061 OLD PESHTIGO RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3887
Practice Address - Country:US
Practice Address - Phone:715-732-8050
Practice Address - Fax:715-732-8015
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129618-121104100000X
WI9378-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100093971Medicaid