Provider Demographics
NPI:1659311967
Name:THOMAS A GONSALVES INCORPORATED
Entity Type:Organization
Organization Name:THOMAS A GONSALVES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION PRIVATE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GONSALVES
Authorized Official - Suffix:
Authorized Official - Credentials:AM LCSW
Authorized Official - Phone:601-551-1327
Mailing Address - Street 1:307 APACHE DRIVE
Mailing Address - Street 2:SUITE B
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:
Practice Address - Street 1:307 APACHE DRIVE
Practice Address - Street 2:SUITE B
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC56471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS279761404AOtherBLUE CROSS BLUE SHIELD
MS01908563Medicaid
MS01908563Medicaid
MS279761404AOtherBLUE CROSS BLUE SHIELD
MS01908563Medicaid