Provider Demographics
NPI:1639598469
Name:GAGNON, MARIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8655 RIVER ROCK CT
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-3592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8655 RIVER ROCK CT
Practice Address - Street 2:
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-3592
Practice Address - Country:US
Practice Address - Phone:770-597-9737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004087225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT004087OtherSTATE LICENSE