Provider Demographics
NPI:1033361191
Name:MCGOVERN, SHANNON (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N EL DORADO PL
Mailing Address - Street 2:# H800B
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4637
Mailing Address - Country:US
Mailing Address - Phone:520-419-6893
Mailing Address - Fax:520-577-2936
Practice Address - Street 1:1200 N EL DORADO PL
Practice Address - Street 2:# H800B
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4637
Practice Address - Country:US
Practice Address - Phone:520-419-6893
Practice Address - Fax:520-577-2936
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3973103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist