Provider Demographics
NPI:1205864527
Name:VAILLANCOURT, ROBERT (MA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:VAILLANCOURT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-0263
Mailing Address - Country:US
Mailing Address - Phone:802-234-5691
Mailing Address - Fax:802-763-7048
Practice Address - Street 1:768 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:VT
Practice Address - Zip Code:05032-4472
Practice Address - Country:US
Practice Address - Phone:802-234-5691
Practice Address - Fax:802-763-7048
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470000611103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist