Provider Demographics
NPI:1336697994
Name:GAGNON, TRACEY (PHD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:KNIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:185 DEVONSHIRE ST STE 901
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:185 DEVONSHIRE ST STE 901
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1485
Practice Address - Country:US
Practice Address - Phone:617-830-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist