Provider Demographics
NPI:1558839563
Name:DEGAGNE, SUZANNE M
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:DEGAGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E MAIN ST FL 1
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3848
Mailing Address - Country:US
Mailing Address - Phone:707-671-2348
Mailing Address - Fax:
Practice Address - Street 1:150 E MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3848
Practice Address - Country:US
Practice Address - Phone:707-671-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101010101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty