Healthcare Provider Details

I. General information

NPI: 1417093188
Provider Name (Legal Business Name): ANTONIO ALEXANDRE GONCALVES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2093 PHILADELPHIA PIKE # 8624
CLAYMONT DE
19703-2424
US

IV. Provider business mailing address

114 CROCKETT RD
KING OF PRUSSIA PA
19406-3014
US

V. Phone/Fax

Practice location:
  • Phone: 610-819-4207
  • Fax:
Mailing address:
  • Phone: 610-337-7434
  • Fax: 610-630-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS015082
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015082
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: