Provider Demographics
NPI:1871961615
Name:CAGNON, ROGER (MA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:CAGNON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 SUMMER ST
Mailing Address - Street 2:SUITE 139
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5783
Mailing Address - Country:US
Mailing Address - Phone:978-345-6729
Mailing Address - Fax:978-342-7503
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:SUITE 139
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5783
Practice Address - Country:US
Practice Address - Phone:978-345-6729
Practice Address - Fax:978-342-7503
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11028046EMedicaid