Provider Demographics
NPI:1619323953
Name:GOVAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2888 E LONG LAKE RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3793
Mailing Address - Country:US
Mailing Address - Phone:248-524-0050
Mailing Address - Fax:248-524-0146
Practice Address - Street 1:2888 E LONG LAKE RD
Practice Address - Street 2:SUITE 170
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3793
Practice Address - Country:US
Practice Address - Phone:248-524-0050
Practice Address - Fax:248-524-0146
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007553106H00000X
MI6401000196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist