Provider Demographics
NPI:1235575762
Name:GAINES, PAUL JR (MSW, LICSW, MED)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:GAINES
Suffix:JR
Gender:
Credentials:MSW, LICSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 BARNETTE ST UNIT 74915
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-1157
Mailing Address - Country:US
Mailing Address - Phone:401-855-4776
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 74915
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99707-4915
Practice Address - Country:US
Practice Address - Phone:401-855-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAISW1216581041C0700X
AK1034171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIISW02768OtherLICSW
AK103417OtherLCSW
MA121658OtherLICSW