Provider Demographics
NPI:1073822946
Name:GAGNON, MARK (MSW, LICSW, LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GAGNON
Suffix:
Gender:M
Credentials:MSW, LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-0612
Mailing Address - Country:US
Mailing Address - Phone:518-321-5592
Mailing Address - Fax:
Practice Address - Street 1:206 GLEN ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3584
Practice Address - Country:US
Practice Address - Phone:518-321-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900544181041C0700X
NY0835531041C0700X
VT000534101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)