Provider Demographics
NPI:1003009432
Name:VAILLANCOURT, KOURTNEY T (PHD, LMFT, LADAC)
Entity Type:Individual
Prefix:DR
First Name:KOURTNEY
Middle Name:T
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PHD, LMFT, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2130
Mailing Address - Country:US
Mailing Address - Phone:575-405-7146
Mailing Address - Fax:575-405-5446
Practice Address - Street 1:619 N ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2130
Practice Address - Country:US
Practice Address - Phone:575-405-7146
Practice Address - Fax:575-405-5446
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0109031101YA0400X
NM0102221101YM0800X
NM0109041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80302386Medicaid