Provider Demographics
NPI:1649037953
Name:GAGNE, REBECCA LEE (BCABA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:GAGNE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:22443-3404
Mailing Address - Country:US
Mailing Address - Phone:540-372-0877
Mailing Address - Fax:
Practice Address - Street 1:1413 TAPPAHANNOCK BLVD # 5
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-9314
Practice Address - Country:US
Practice Address - Phone:804-203-2011
Practice Address - Fax:540-898-1040
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000548106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst