Provider Demographics
NPI:1235261868
Name:GONSALVES, RICARDO EUGENIO (EDD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:EUGENIO
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:RICARDO
Other - Middle Name:EUGENIO
Other - Last Name:GONSALVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:1300 NUTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3309
Mailing Address - Country:US
Mailing Address - Phone:714-308-4819
Mailing Address - Fax:
Practice Address - Street 1:1300 NUTWOOD AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3309
Practice Address - Country:US
Practice Address - Phone:714-308-4819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist