Provider Demographics
NPI:1841409380
Name:VAILLANCOURT, MICHAEL JOSEPH (MSW, EDM)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:VAILLANCOURT
Suffix:
Gender:M
Credentials:MSW, EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CAMEO CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08823-1603
Mailing Address - Country:US
Mailing Address - Phone:732-940-8992
Mailing Address - Fax:
Practice Address - Street 1:385 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2570
Practice Address - Country:US
Practice Address - Phone:201-487-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ00425288390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program