Healthcare Provider Details

I. General information

NPI: 1841409380
Provider Name (Legal Business Name): MICHAEL JOSEPH VAILLANCOURT MSW, ED.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

10 CAMEO CT
FRANKLIN PARK NJ
08823-1603
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-1390
  • Fax:
Mailing address:
  • Phone: 732-940-8992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SC05629600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: