Provider Demographics
NPI:1861840696
Name:MCGOVERN, ELISSA
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 THORNHILL DR
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2706
Mailing Address - Country:US
Mailing Address - Phone:630-752-9750
Mailing Address - Fax:
Practice Address - Street 1:507 THORNHILL DR
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:630-752-9750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical