Provider Demographics
NPI:1437786134
Name:MCGOVERN, MARK (LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 S COLLEGE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5404
Mailing Address - Country:US
Mailing Address - Phone:970-482-5301
Mailing Address - Fax:
Practice Address - Street 1:2111 S COLLEGE AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5404
Practice Address - Country:US
Practice Address - Phone:970-482-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019178225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist