Provider Demographics
NPI:1285975631
Name:VAILLANCOURT, DIANE (MA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 NIEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2057
Mailing Address - Country:US
Mailing Address - Phone:516-887-4529
Mailing Address - Fax:
Practice Address - Street 1:2857 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5126
Practice Address - Country:US
Practice Address - Phone:718-235-3100
Practice Address - Fax:718-277-0822
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist