Provider Demographics
NPI:1922554120
Name:NICKERSON GAUTHIER, KAYLA (LMFT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:NICKERSON GAUTHIER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 ROSS HILL RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2824
Mailing Address - Country:US
Mailing Address - Phone:860-373-8802
Mailing Address - Fax:
Practice Address - Street 1:41 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-961-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CT1832106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist