Provider Demographics
NPI:1093251084
Name:GAGNERON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GAGNERON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GAGNERON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:1042 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-5547
Mailing Address - Country:US
Mailing Address - Phone:917-667-4667
Mailing Address - Fax:
Practice Address - Street 1:100 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-2601
Practice Address - Country:US
Practice Address - Phone:212-519-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078147-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical