Provider Demographics
NPI:1316032774
Name:GONCALO, MARY (RN, MS, CS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GONCALO
Suffix:
Gender:F
Credentials:RN, MS, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 365
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-0365
Mailing Address - Country:US
Mailing Address - Phone:774-644-5629
Mailing Address - Fax:508-678-8100
Practice Address - Street 1:101 SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-6812
Practice Address - Country:US
Practice Address - Phone:774-644-5629
Practice Address - Fax:508-678-8100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA197997163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI410198-001OtherBLUE CHIP
MAPN0790OtherBLUE CROSS BLUE CHIELD
000000024517OtherBOSTON MEDICAL HEALTHNET
103300OtherNHP
MA11089087AMedicaid
60054OtherAETNA
MA1894480Medicaid
RI214375OtherBC BS OF RI
585968000OtherMAGELLAN
RI410198-001OtherBLUE CHIP
60054OtherAETNA