Provider Demographics
NPI:1235914722
Name:GAGNE, NICOLE MARIE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:GAGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:GONYEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01524-2007
Mailing Address - Country:US
Mailing Address - Phone:978-390-3489
Mailing Address - Fax:
Practice Address - Street 1:52 LAKE DR
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:MA
Practice Address - Zip Code:01524-2007
Practice Address - Country:US
Practice Address - Phone:978-390-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty