Healthcare Provider Details

I. General information

NPI: 1700450459
Provider Name (Legal Business Name): JUDY GAGNON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 MAIN ST STE 308
SPRINGVALE ME
04083-1872
US

IV. Provider business mailing address

64 MERCHANTS ROW
LEBANON ME
04027-4305
US

V. Phone/Fax

Practice location:
  • Phone: 207-698-0475
  • Fax:
Mailing address:
  • Phone: 603-285-5814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC22727
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: