Provider Demographics
NPI:1255957072
Name:GAGNON, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:NH
Mailing Address - Zip Code:03222-3503
Mailing Address - Country:US
Mailing Address - Phone:603-530-2545
Mailing Address - Fax:
Practice Address - Street 1:75 BAKER ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:NH
Practice Address - Zip Code:03222-3503
Practice Address - Country:US
Practice Address - Phone:603-530-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician