Provider Demographics
NPI:1417093188
Name:GONCALVES, ANTONIO ALEXANDRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:ALEXANDRE
Last Name:GONCALVES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 CROCKETT RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3014
Mailing Address - Country:US
Mailing Address - Phone:610-337-7434
Mailing Address - Fax:610-630-7806
Practice Address - Street 1:114 CROCKETT RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3014
Practice Address - Country:US
Practice Address - Phone:610-337-7434
Practice Address - Fax:610-630-7806
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
PAPS015082103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25561Medicare UPIN