Provider Demographics
NPI:1427197300
Name:GAGNE, JANET M (MA LP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:M
Last Name:GAGNE
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:GAGNE
Other - Middle Name:
Other - Last Name:INCORPORATED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4301 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1954
Mailing Address - Country:US
Mailing Address - Phone:952-920-2772
Mailing Address - Fax:
Practice Address - Street 1:4301 W 62ND ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1954
Practice Address - Country:US
Practice Address - Phone:952-920-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP3951OtherSTATEPSYCHOLOGY LICENSE
MN1575334OtherMINNESOTA TAX ID