Provider Demographics
NPI:1942438858
Name:GONSALVES, STACY A
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CRANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-1349
Mailing Address - Country:US
Mailing Address - Phone:508-951-7479
Mailing Address - Fax:
Practice Address - Street 1:126 COVE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-1306
Practice Address - Country:US
Practice Address - Phone:508-678-0041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312677Medicaid
MA685661OtherTUFTS