Provider Demographics
NPI:1558918607
Name:GONSALVES, VALERIE M (PHD)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:M
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4338
Mailing Address - Country:US
Mailing Address - Phone:773-304-6737
Mailing Address - Fax:
Practice Address - Street 1:3099 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4338
Practice Address - Country:US
Practice Address - Phone:773-304-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558918607Medicaid