Provider Demographics
NPI:1760143770
Name:GAGNE, AMBER J (PLADC)
Entity Type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:J
Last Name:GAGNE
Suffix:
Gender:F
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 DEER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-1917
Mailing Address - Country:US
Mailing Address - Phone:402-558-7088
Mailing Address - Fax:
Practice Address - Street 1:2052 DEER PARK BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68108-1917
Practice Address - Country:US
Practice Address - Phone:402-558-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1895101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)