Healthcare Provider Details

I. General information

NPI: 1710450648
Provider Name (Legal Business Name): PATRICIA GAGNON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA WOOD BCBA

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 AUBURN ST
MANCHESTER NH
03103-4803
US

IV. Provider business mailing address

555 AUBURN ST
MANCHESTER NH
03103-4803
US

V. Phone/Fax

Practice location:
  • Phone: 603-621-3516
  • Fax: 603-622-8101
Mailing address:
  • Phone: 603-621-3516
  • Fax: 603-622-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-34317
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: