Provider Demographics
NPI:1720565658
Name:GAGNON, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 PINE NOOK ROAD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01342
Mailing Address - Country:US
Mailing Address - Phone:802-380-3392
Mailing Address - Fax:
Practice Address - Street 1:271 PINE NOOK ROAD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01342-0134
Practice Address - Country:US
Practice Address - Phone:802-380-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0001205151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical