Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1760008338 |
---|---|
Provider Name | Addison Gagnon |
First Address | Bangor, ME 04401-3945 |
Second Address | Bangor, ME 04401-3945 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2020 |
Last Update Date | 19/06/2020 |