Provider Demographics
NPI:1801783022
Name:GAGNON, MICHAEL TYLER (RBT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
Last Name:GAGNON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6416
Mailing Address - Country:US
Mailing Address - Phone:575-495-9911
Mailing Address - Fax:910-229-2714
Practice Address - Street 1:816 9TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6416
Practice Address - Country:US
Practice Address - Phone:575-495-9911
Practice Address - Fax:910-229-2714
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRBT-25-445210106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician