Provider Demographics
NPI:1124437132
Name:VAILLANCOURT, AMBER (M ED COMS)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:M ED COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1114
Mailing Address - Country:US
Mailing Address - Phone:781-687-4308
Mailing Address - Fax:
Practice Address - Street 1:200 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1114
Practice Address - Country:US
Practice Address - Phone:781-687-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH68542255R0406X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6854OtherACVREP