Provider Demographics
NPI:1679608905
Name:GAGNON, SUSAN MARIE (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:MSW, LCSW
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 413
Mailing Address - Street 2:937 SOUTH MAIN ST., UNIT 4
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-0413
Mailing Address - Country:US
Mailing Address - Phone:860-384-9104
Mailing Address - Fax:860-426-0596
Practice Address - Street 1:937 SOUTH MAIN ST
Practice Address - Street 2:UNIT 4
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-0413
Practice Address - Country:US
Practice Address - Phone:860-384-9104
Practice Address - Fax:860-426-0596
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0029671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002967OtherLCSW LICENSE