Provider Demographics
NPI:1144496878
Name:GONSALVES, CLARENCE D
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:D
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 MOUNT VERNON ST # 2
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6714
Mailing Address - Country:US
Mailing Address - Phone:857-247-7425
Mailing Address - Fax:
Practice Address - Street 1:321 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02121-4302
Practice Address - Country:US
Practice Address - Phone:617-541-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS71703937171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator