Provider Demographics
NPI:1134139058
Name:VAILLANCOURT, MAVIS H (LCSW, LAC)
Entity Type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:H
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2131
Mailing Address - Country:US
Mailing Address - Phone:406-546-8507
Mailing Address - Fax:
Practice Address - Street 1:415 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2131
Practice Address - Country:US
Practice Address - Phone:406-546-8507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9121041C0700X
MT1140101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)