Provider Demographics
NPI:1679302467
Name:GONSALVES, COHLTON BENJAMIN (RBT)
Entity type:Individual
Prefix:
First Name:COHLTON
Middle Name:BENJAMIN
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 WILLOWLEAF DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3683
Mailing Address - Country:US
Mailing Address - Phone:650-580-5623
Mailing Address - Fax:
Practice Address - Street 1:1835 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1629
Practice Address - Country:US
Practice Address - Phone:669-267-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst