Provider Demographics
NPI:1134420466
Name:GAGNON, DANIELLE LEE (LSW-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LEE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HANCOCK ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6573
Mailing Address - Country:US
Mailing Address - Phone:207-989-5701
Mailing Address - Fax:207-989-5720
Practice Address - Street 1:304 HANCOCK ST STE 2C
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6573
Practice Address - Country:US
Practice Address - Phone:207-989-5701
Practice Address - Fax:207-989-5720
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX11070171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator