Healthcare Provider Details

I. General information

NPI: 1316032774
Provider Name (Legal Business Name): MARY GONCALO RN, MS, CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SULLIVAN DR
FALL RIVER MA
02721-6812
US

IV. Provider business mailing address

P O BOX 365
SOMERSET MA
02726-0365
US

V. Phone/Fax

Practice location:
  • Phone: 774-644-5629
  • Fax: 508-678-8100
Mailing address:
  • Phone: 774-644-5629
  • Fax: 508-678-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number197997
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: