Provider Demographics
NPI:1043017643
Name:LACOSSE, ROBERT JOSEPH
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:LACOSSE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2603
Mailing Address - Country:US
Mailing Address - Phone:707-474-2650
Mailing Address - Fax:707-514-7180
Practice Address - Street 1:5325 N FRESNO ST STE 106
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6849
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2025-03-01
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician