Provider Demographics
NPI:1609424795
Name:GONSALVES, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1117
Mailing Address - Country:US
Mailing Address - Phone:508-446-4394
Mailing Address - Fax:
Practice Address - Street 1:345A GREENWOOD ST STE B
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1753
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist