Provider Demographics
NPI:1780684274
Name:GAGNON, JAMES M (PHD, MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:M
Last Name:GAGNON
Suffix:
Gender:M
Credentials:PHD, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 OFFICE PLZ
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2808
Mailing Address - Country:US
Mailing Address - Phone:850-877-0205
Mailing Address - Fax:850-877-1129
Practice Address - Street 1:220 OFFICE PLZ
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2808
Practice Address - Country:US
Practice Address - Phone:850-877-0205
Practice Address - Fax:850-877-1129
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW4770103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z7930Medicare ID - Type Unspecified