Healthcare Provider Details

I. General information

NPI: 1134289788
Provider Name (Legal Business Name): KATE VAILLANCOURT PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATE AIREY BA

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 WOODBURY AVE
NEWINGTON NH
03801-7854
US

IV. Provider business mailing address

2299 WOODBURY AVE
NEWINGTON NH
03801-7854
US

V. Phone/Fax

Practice location:
  • Phone: 978-572-0703
  • Fax:
Mailing address:
  • Phone: 978-572-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1344
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: