Provider Demographics
NPI:1588725055
Name:GAGNE, JULIE LYNN (MSW)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:LYNN
Last Name:GAGNE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CONDIT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1058
Mailing Address - Country:US
Mailing Address - Phone:651-603-5823
Mailing Address - Fax:
Practice Address - Street 1:450 SYNDICATE ST N
Practice Address - Street 2:SUITE 5
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4107
Practice Address - Country:US
Practice Address - Phone:651-603-5823
Practice Address - Fax:651-603-5990
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN161081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN66611730Medicaid