Basic Information
| Provider Information | |||||||||
| NPI: | 1255340832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW, BCD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 157 | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707040157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256362638 | ||||||||
| FaxNumber: | 2257785068 | ||||||||
| Practice Location | |||||||||
| Address1: | 2944 RAY WEILAND DR | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707143250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256362638 | ||||||||
| FaxNumber: | 2257785068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1656 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X | LA | N | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1438341 | 05 | LA | MEDICAID |