Provider Demographics
NPI:1710061338
Name:GAGNON BLODGETT, MICHELLE DAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DAWN
Last Name:GAGNON BLODGETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12905 MILFORD CT
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6235
Mailing Address - Country:US
Mailing Address - Phone:954-262-5611
Mailing Address - Fax:954-262-3557
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-5611
Practice Address - Fax:954-262-2276
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6028103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist