Provider Demographics
NPI:1518173525
Name:GONSALVES, THOMAS A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 APACHE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-6309
Mailing Address - Country:US
Mailing Address - Phone:601-551-1327
Mailing Address - Fax:601-591-5040
Practice Address - Street 1:307 APACHE DR STE B
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-6309
Practice Address - Country:US
Practice Address - Phone:601-551-1327
Practice Address - Fax:601-591-5040
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC56471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01908563Medicaid
MSP78195Medicare UPIN