Provider Demographics
NPI:1710430665
Name:KOVIN, ALAN (LASAC)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:
Last Name:KOVIN
Suffix:
Gender:M
Credentials:LASAC
Other - Prefix:MR
Other - First Name:ALAN
Other - Middle Name:
Other - Last Name:KOVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LASAC
Mailing Address - Street 1:5017 N 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7317
Mailing Address - Country:US
Mailing Address - Phone:602-477-9562
Mailing Address - Fax:
Practice Address - Street 1:5017 N 62ND AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7317
Practice Address - Country:US
Practice Address - Phone:602-477-9562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-13281101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ045584Medicaid