Provider Demographics
NPI:1619412947
Name:MCGOVERN, CAROLYN (OT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3084
Mailing Address - Country:US
Mailing Address - Phone:315-418-4013
Mailing Address - Fax:315-478-0388
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3084
Practice Address - Country:US
Practice Address - Phone:315-418-4013
Practice Address - Fax:315-478-0388
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist