Provider Demographics
NPI:1417093188
Name:GONCALVES, ANTONIO ALEXANDRE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:ALEXANDRE
Last Name:GONCALVES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 CROCKETT RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3014
Mailing Address - Country:US
Mailing Address - Phone:610-337-7434
Mailing Address - Fax:610-630-7806
Practice Address - Street 1:2093 PHILADELPHIA PIKE # 8624
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2424
Practice Address - Country:US
Practice Address - Phone:610-819-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015082103T00000X, 103TC0700X
103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25561Medicare UPIN