Provider Demographics
NPI:1255340832
Name:GAINES, MICHAEL DAN (MSW, LCSW, BCD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAN
Last Name:GAINES
Suffix:
Gender:M
Credentials:MSW, LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70704-0157
Mailing Address - Country:US
Mailing Address - Phone:225-636-2638
Mailing Address - Fax:225-778-5068
Practice Address - Street 1:2944 RAY WEILAND DR
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3250
Practice Address - Country:US
Practice Address - Phone:225-636-2638
Practice Address - Fax:225-778-5068
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16561041C0700X
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1438341Medicaid
LA3C915Medicare PIN