Provider Demographics
NPI:1437661402
Name:GAGNER, KELLY (BA, MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GAGNER
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PACHECO-GAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, MS
Mailing Address - Street 1:1341 N ESCONDIDO BLVD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2507
Mailing Address - Country:US
Mailing Address - Phone:760-747-1015
Mailing Address - Fax:
Practice Address - Street 1:1341 N ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2507
Practice Address - Country:US
Practice Address - Phone:760-317-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC5939101YM0800X
101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)