Provider Demographics
NPI:1104696251
Name:LACOURCIERE, RENEE (CLINICAL DOCTOR/SLP)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:LACOURCIERE
Suffix:
Gender:F
Credentials:CLINICAL DOCTOR/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BAYONET ST STE 304
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2600
Mailing Address - Country:US
Mailing Address - Phone:860-304-7057
Mailing Address - Fax:
Practice Address - Street 1:16 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:IVORYTON
Practice Address - State:CT
Practice Address - Zip Code:06442-1252
Practice Address - Country:US
Practice Address - Phone:860-304-7057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT09147114235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist