Provider Demographics
NPI:1770635468
Name:GONSALVES, JANELLE R (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JANELLE
Middle Name:R
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LA CASA VIA
Mailing Address - Street 2:SUITE 212
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3067
Mailing Address - Country:US
Mailing Address - Phone:925-939-8710
Mailing Address - Fax:925-939-8716
Practice Address - Street 1:120 LA CASA VIA
Practice Address - Street 2:SUITE 212
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3067
Practice Address - Country:US
Practice Address - Phone:925-939-8710
Practice Address - Fax:925-939-8716
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056674Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER