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General NPI Number Information
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NPI Number | 1699229682
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Entity Type | Organization
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Legal Business Name | MAVIS VAILLANCOURT LCSW LAC LLC
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Dates
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Enumeration Date | 08/08/2016
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 415 LOUISIANA AVE
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City | LIBBY
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State | MT
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Zip | 59923-2131
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Country | US
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Telephone | 406-546-8507
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Fax |
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Provider Business Mailing Address
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Address Line | 415 LOUISIANA AVE
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City | LIBBY
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State | MT
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Zip | 59923-2131
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MAVIS VAILLANCOURT
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Credential | LCSW LAC
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Telephone | 406-546-8507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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