Provider Demographics
NPI:1891915666
Name:GONSALVES, MARK A (LADC 1)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3343
Mailing Address - Country:US
Mailing Address - Phone:508-992-3369
Mailing Address - Fax:
Practice Address - Street 1:200 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2525
Practice Address - Country:US
Practice Address - Phone:508-540-6550
Practice Address - Fax:508-540-7480
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1531101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)