Provider Demographics
NPI:1699229682
Name:MAVIS VAILLANCOURT LCSW LAC LLC
Entity type:Organization
Organization Name:MAVIS VAILLANCOURT LCSW LAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAILLANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW LAC
Authorized Official - Phone:406-546-8507
Mailing Address - Street 1:415 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2131
Practice Address - Country:US
Practice Address - Phone:406-546-8507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center