Healthcare Provider Details

I. General information

NPI: 1811442148
Provider Name (Legal Business Name): MISS CHELSEA REMAH GONSALVES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR SUITE LL 105/108
PLAINVIEW NY
11803-1718
US

IV. Provider business mailing address

118 N 16TH ST
POTTSVILLE PA
17901-2112
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-2040
  • Fax:
Mailing address:
  • Phone: 570-640-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number020796
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: