Healthcare Provider Details

I. General information

NPI: 1659135986
Provider Name (Legal Business Name): PSYCHIATRIC EDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 DUPORTAIL RD FL 2
CHESTERBROOK PA
19087-5575
US

IV. Provider business mailing address

851 DUPORTAIL RD FL 2
CHESTERBROOK PA
19087-5575
US

V. Phone/Fax

Practice location:
  • Phone: 856-699-1719
  • Fax: 856-249-9109
Mailing address:
  • Phone: 856-699-1719
  • Fax: 856-249-9109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH RICHARD GAGNON JR.
Title or Position: OWNER
Credential: CRNP,PMHNP-BC, MSN
Phone: 856-699-1719