Provider Demographics
NPI:1164805891
Name:MCGOVERN, MARK P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:MCGOVERN
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 1:85 MECHANIC ST
Mailing Address - Street 2:SUITE B4-1
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1537
Mailing Address - Country:US
Mailing Address - Phone:603-381-1160
Mailing Address - Fax:603-448-3976
Practice Address - Street 1:85 MECHANIC ST
Practice Address - Street 2:SUITE B4-1
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1537
Practice Address - Country:US
Practice Address - Phone:603-381-1160
Practice Address - Fax:603-448-3976
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH932103T00000X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)