MEDICARE: NEVAEH RAE GONSALVES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1861142317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEVAEH RAE GONSALVES

Provider Business Mailing Address
First Line	:	1631 NW SAINT LUCIE WEST BLVD STE 207
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-1963
Country	:	US
Telephone Number	:	772-237-1731
Fax Number	:

Provider Business Practice Location Address
First Line	:	1631 NW SAINT LUCIE WEST BLVD STE 207
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-1963
Country	:	US
Telephone Number	:	772-237-1731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2022
Last Update Date	:	06/04/2024

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