Provider Demographics
NPI:1467229401
Name:GAGNON, MARK ANTHONY GEORGE JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY GEORGE
Last Name:GAGNON
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2875 S ORANGE AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-5455
Mailing Address - Country:US
Mailing Address - Phone:321-355-2157
Mailing Address - Fax:
Practice Address - Street 1:240 BONITA DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5102
Practice Address - Country:US
Practice Address - Phone:321-355-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW222461041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical