Provider Information for 1265940019
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TARA LACOURSIERE
Sex: Female
NPI: 1265940019
Last Updated: 2023-05-30
Certification Date: 2023-05-30
Certification Date: 2023-05-30
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1265940019 | ||||||||||||
| Enumeration Date | 2018-01-15 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 610 WAMPANOAG TRL RIVERSIDE, RI 02915-1504 United States Phone: 401-749-7698 | Fax: | ||||||||||||
| Primary Practice Address | 455 TOLL GATE RD WARWICK, RI 02886-2759 United States Phone: 401-737-7010 | Fax:401-736-4546 | ||||||||||||
| Secondary Practice Address(es) | 604 DEVILS FOOT RD APT 2 | ||||||||||||
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