Healthcare Provider Details

I. General information

NPI: 1396994711
Provider Name (Legal Business Name): ERIN ANNE GAGNON ERIN GAGNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ERIN ANNE GAGNON OTR/L, L.AC. MAOM

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 FOREST AVE STE 204
PORTLAND ME
04103-3336
US

IV. Provider business mailing address

980 FOREST AVE STE 204
PORTLAND ME
04103-3336
US

V. Phone/Fax

Practice location:
  • Phone: 207-831-3703
  • Fax:
Mailing address:
  • Phone: 207-831-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1068
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC351
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: