Provider Demographics
NPI:1629548623
Name:GONCALVES, LINDA CAROL (LMT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:CAROL
Last Name:GONCALVES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3137
Mailing Address - Country:US
Mailing Address - Phone:631-525-7476
Mailing Address - Fax:
Practice Address - Street 1:348 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4507
Practice Address - Country:US
Practice Address - Phone:516-921-3468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9454920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist