Provider Demographics
NPI:1124170550
Name:GAGNE, LARA PATRICE
Entity type:Individual
Prefix:MISS
First Name:LARA
Middle Name:PATRICE
Last Name:GAGNE
Suffix:
Gender:F
Credentials:
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 544
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:CA
Mailing Address - Zip Code:94517-0544
Mailing Address - Country:US
Mailing Address - Phone:925-603-0186
Mailing Address - Fax:
Practice Address - Street 1:1044 NORTHWEST BLVD STE C
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2114
Practice Address - Country:US
Practice Address - Phone:208-930-1740
Practice Address - Fax:208-930-1695
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAREG. INTERN 48617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist