Provider Demographics
NPI:1689867244
Name:FLANAGAN, GAVIN (MA)
Entity Type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:
Last Name:FLANAGAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-0322
Mailing Address - Country:US
Mailing Address - Phone:802-735-9080
Mailing Address - Fax:815-572-0389
Practice Address - Street 1:1028 LAKE DUNMORE RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:VT
Practice Address - Zip Code:05769-9755
Practice Address - Country:US
Practice Address - Phone:802-735-9080
Practice Address - Fax:815-572-0389
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0089767101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271177Medicaid
OR0000WCBBCMedicare PIN
OR1235164559Medicare UPIN