Provider Demographics
NPI:1033690003
Name:GAUTHIER, LUCAS D (DPT)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:D
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-560-1083
Mailing Address - Fax:920-560-1098
Practice Address - Street 1:1931 MARINETTE AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3801
Practice Address - Country:US
Practice Address - Phone:715-735-5500
Practice Address - Fax:715-735-5502
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14425-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14425-24OtherSTATE LICENSE