Provider Demographics
NPI:1790298453
Name:GONSALVES, DAMIEN (MFTI)
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 1/3 W KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6022 VARIEL AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-3719
Practice Address - Country:US
Practice Address - Phone:818-274-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76991103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical