Provider Demographics
NPI:1710640479
Name:GAGNON, GREGORY JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOSEPH
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 1:635 W 165TH ST RM 618
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3724
Mailing Address - Country:US
Mailing Address - Phone:212-305-4668
Mailing Address - Fax:
Practice Address - Street 1:215 W 88TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2324
Practice Address - Country:US
Practice Address - Phone:646-389-3466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical