Provider Demographics
NPI:1588898282
Name:LACOURSE, PHILLIP GERARD (MA,LLP)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:GERARD
Last Name:LACOURSE
Suffix:
Gender:M
Credentials:MA,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 E 13 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-8711
Mailing Address - Country:US
Mailing Address - Phone:586-558-7472
Mailing Address - Fax:
Practice Address - Street 1:8150 E 13 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8711
Practice Address - Country:US
Practice Address - Phone:586-558-7472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007404101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)