Provider Demographics
NPI:1477910453
Name:GONSALVES, TIFFANY (MSED)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 E 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3435
Mailing Address - Country:US
Mailing Address - Phone:212-300-5001
Mailing Address - Fax:
Practice Address - Street 1:603 E 83RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3435
Practice Address - Country:US
Practice Address - Phone:212-300-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1001236151252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency