Healthcare Provider Details

I. General information

NPI: 1033228176
Provider Name (Legal Business Name): SANDRA GONSALVES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHURCH ST SUITE 202
YALESVILLE CT
06492-2253
US

IV. Provider business mailing address

1381 RHEY AVE
WALLINGFORD CT
06492-3314
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-7770
  • Fax: 203-294-0536
Mailing address:
  • Phone: 203-265-7562
  • Fax: 203-294-0536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005483
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: