Basic Information
| Provider Information | |||||||||
| NPI: | 1003009432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAILLANCOURT | ||||||||
| FirstName: | KOURTNEY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D, LMFT, LADAC | ||||||||
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| 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: | 619 N ALAMEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880052130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754057146 | ||||||||
| FaxNumber: | 5754055446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0109031 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 0102221 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 0109041 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 80302386 | 05 | NM | MEDICAID |