Provider Demographics
NPI:1316097736
Name:LACOURT, DAVID JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOSEPH
Last Name:LACOURT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 GREEN ACRES LN
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9017
Mailing Address - Country:US
Mailing Address - Phone:505-869-1801
Mailing Address - Fax:505-869-1640
Practice Address - Street 1:4004 CARLISLE BLVD NE
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4565
Practice Address - Country:US
Practice Address - Phone:505-830-1629
Practice Address - Fax:505-869-1640
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM525103T00000X
MN6301002442103T00000X
NM240926103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0981Medicaid