MEDICARE: BERONICA E. GONSALVES M.S. ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		NY

General Provider Information

NPI Number	:	1740525435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERONICA E. GONSALVES M.S. ED.

Provider Business Mailing Address
First Line	:	120 CARVER LOOP
Second Line	:	APT 19-E
City	:	BRONX
State	:	NY
Zip	:	10475-2902
Country	:	US
Telephone Number	:	718-409-4227
Fax Number	:

Provider Business Practice Location Address
First Line	:	2433 E TREMONT AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-2801
Country	:	US
Telephone Number	:	718-409-4227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2012
Last Update Date	:	12/06/2012

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