Provider Demographics
NPI:1114478435
Name:VAILLANCOURT, DYLAN A
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:A
Last Name:VAILLANCOURT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CATHEDRAL DR
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-6246
Mailing Address - Country:US
Mailing Address - Phone:774-331-1223
Mailing Address - Fax:
Practice Address - Street 1:68 CATHEDRAL DR
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-6246
Practice Address - Country:US
Practice Address - Phone:774-331-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health