Provider Demographics
NPI:1861040065
Name:GAINES, MIREILLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MIREILLE
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 MAIN ST
Mailing Address - Street 2:STE 512
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3787
Mailing Address - Country:US
Mailing Address - Phone:203-362-3900
Mailing Address - Fax:
Practice Address - Street 1:1204 MAIN ST
Practice Address - Street 2:STE 512
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3787
Practice Address - Country:US
Practice Address - Phone:220-362-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003782101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor