Provider Demographics
NPI:1730217274
Name:GAGNON, MARJORIE E (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:E
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LICSW
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 426
Mailing Address - Street 2:48 A ST
Mailing Address - City:WEST WARREN
Mailing Address - State:MA
Mailing Address - Zip Code:01092-0426
Mailing Address - Country:US
Mailing Address - Phone:413-436-5364
Mailing Address - Fax:413-436-5364
Practice Address - Street 1:21 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007-9159
Practice Address - Country:US
Practice Address - Phone:413-323-4773
Practice Address - Fax:413-323-7687
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10245471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P07463OtherBC BS
P07463OtherBC BS