Provider Demographics
NPI:1285808303
Name:GONSALVES, VINCENT A (PT)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:A
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9445 SW LOCUST ST
Mailing Address - Street 2:WORK & WELLNESS
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6634
Mailing Address - Country:US
Mailing Address - Phone:503-595-8806
Mailing Address - Fax:
Practice Address - Street 1:9445 SW LOCUST ST
Practice Address - Street 2:WORK & WELLNESS
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6634
Practice Address - Country:US
Practice Address - Phone:503-595-8806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9609-024225100000X
OR6196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI87OtherDEAN HEALTH INSURANCE