MEDICARE: ROBERT VAILLANCOURT M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0470000611	VT

General Provider Information

NPI Number	:	1205864527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT VAILLANCOURT M.A.

Provider Business Mailing Address
First Line	:	PO BOX 263
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-0263
Country	:	US
Telephone Number	:	802-234-5691
Fax Number	:	802-763-7048

Provider Business Practice Location Address
First Line	:	768 S MAIN ST
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-4472
Country	:	US
Telephone Number	:	802-234-5691
Fax Number	:	802-763-7048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	12/12/2018

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