Provider Demographics
NPI:1700097441
Name:VAILLANCOURT, CAROLYN (PT MS NCS)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PT MS NCS
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:KUBASKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT MS NCS
Mailing Address - Street 1:86 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-849-7973
Mailing Address - Fax:781-356-1820
Practice Address - Street 1:751 GRANITE ST
Practice Address - Street 2:BRAINTREE PEDIATRIC CENTER
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:781-380-4360
Practice Address - Fax:781-356-1820
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist