Provider Demographics
NPI:1417219817
Name:GAGNE, LAURENCE N
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:N
Last Name:GAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 STEPPING STONE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3951
Mailing Address - Country:US
Mailing Address - Phone:207-347-1309
Mailing Address - Fax:
Practice Address - Street 1:4 STEPPING STONE LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3951
Practice Address - Country:US
Practice Address - Phone:207-347-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional