Provider Demographics
NPI:1295292373
Name:GONSALVES, ANTOINETTE (MACP)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 DUNKSFERRY RD APT H104
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2734
Mailing Address - Country:US
Mailing Address - Phone:323-829-1022
Mailing Address - Fax:
Practice Address - Street 1:4 NESHAMINY INTERPLEX DR STE 202
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6940
Practice Address - Country:US
Practice Address - Phone:323-829-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician