Provider Demographics
NPI:1679789234
Name:GAGNON, JOHN H (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:GAGNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 OAKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3518
Mailing Address - Country:US
Mailing Address - Phone:203-316-0881
Mailing Address - Fax:
Practice Address - Street 1:233 OAKLAWN AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3518
Practice Address - Country:US
Practice Address - Phone:203-326-5657
Practice Address - Fax:203-316-0881
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000112106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist