Provider Demographics
NPI:1013408681
Name:GAGNON, TAMMY M (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:M
Last Name:GAGNON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CIVIC CENTER PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7718
Mailing Address - Country:US
Mailing Address - Phone:507-345-4679
Mailing Address - Fax:507-345-8685
Practice Address - Street 1:11 CIVIC CENTER PLZ STE 1615
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7710
Practice Address - Country:US
Practice Address - Phone:507-345-4679
Practice Address - Fax:507-345-8685
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN223861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical