Provider Demographics
NPI:1093717084
Name:MCGOVERN, RENE J (PH D)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:J
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 E 3RD AVE
Mailing Address - Street 2:UNIT 405
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4451
Mailing Address - Country:US
Mailing Address - Phone:660-341-5030
Mailing Address - Fax:480-773-6063
Practice Address - Street 1:7301 E 3RD AVE
Practice Address - Street 2:UNIT 405
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-4451
Practice Address - Country:US
Practice Address - Phone:660-341-5030
Practice Address - Fax:480-773-6063
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499779817Medicaid
MO000071300Medicare PIN