Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PS015082 | PA |
N | 103T00000X | Psychologist | PS015082 | PA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103G00000X | Clinical Psychologist | PS015082 | PA |
N | 103TC0700X | Clinical Psychologist | PS015082 | PA |
NPI | 1417093188 |
---|---|
Provider Name | Dr. Antonio Alexandre Goncalves |
First Address | King Of Prussia, PA 19406-3014 |
Second Address | King Of Prussia, PA 19406-3014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25561 | (02) | PA |