Provider Demographics
NPI:1538277009
Name:GAGNON, LISA A (MSW,LICSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:GAGNON
Suffix:
Gender:F
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 JAQUES AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2476
Mailing Address - Country:US
Mailing Address - Phone:508-860-1154
Mailing Address - Fax:508-792-9814
Practice Address - Street 1:72 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1154
Practice Address - Fax:508-792-9814
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health