Provider Demographics
NPI:1013499615
Name:GAGNE, CHRISTINE GOUGH (LICSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GOUGH
Last Name:GAGNE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2317
Mailing Address - Country:US
Mailing Address - Phone:508-393-2862
Mailing Address - Fax:
Practice Address - Street 1:33 SUNSET DR
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-2317
Practice Address - Country:US
Practice Address - Phone:508-393-2862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1021125-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical