Healthcare Provider Details

I. General information

NPI: 1134200850
Provider Name (Legal Business Name): RACHEL Y GONSALVES PT, MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 WILLOW RD
MENLO PARK CA
94025-3653
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 866-839-6979
  • Fax:
Mailing address:
  • Phone: 217-366-1326
  • Fax: 217-366-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-012116
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070012116
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: