Basic Information
Provider Information
NPI: 1003009432
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VAILLANCOURT
FirstName: KOURTNEY
MiddleName: T.
NamePrefix: DR.
NameSuffix:  
Credential: PH.D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 505 S MAIN ST
Address2: 129 LORETTO TOWNE CENTRE
City: LAS CRUCES
State: NM
PostalCode: 880011206
CountryCode: US
TelephoneNumber: 5755255644
FaxNumber: 5755255637
Practice Location
Address1: 505 S MAIN ST
Address2: 129 LORETTO TOWNE CENTRE
City: LAS CRUCES
State: NM
PostalCode: 880011206
CountryCode: US
TelephoneNumber: 5755255644
FaxNumber: 5755255637
Other Information
ProviderEnumerationDate: 08/20/2007
LastUpdateDate: 04/08/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X0109031NMN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800X0102221NMY Behavioral Health & Social Service ProvidersCounselorMental Health
106H00000X0109041NMN Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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