Basic Information
| Provider Information | |||||||||
| NPI: | 1063859015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAILLANCOURT ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | STE. 129 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755255644 | ||||||||
| FaxNumber: | 5755255637 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | STE. 129 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755255644 | ||||||||
| FaxNumber: | 5755255637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2013 | ||||||||
| LastUpdateDate: | 05/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | VAILLANCOURT | ||||||||
| AuthorizedOfficialFirstName: | KOURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5755255644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, LMFT, LADAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0109041 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 80302386 | 05 | NM | MEDICAID |