Healthcare Provider Details

I. General information

NPI: 1295715480
Provider Name (Legal Business Name): JOHN MICHAEL GAGNON LMSW, CAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S LINCOLN RD
ESCANABA MI
49829-1215
US

IV. Provider business mailing address

PO BOX 22040
GREEN BAY WI
54305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 906-786-6488
  • Fax: 906-786-6409
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801057230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: