Provider Demographics
NPI:1245368117
Name:MCGOVERN, KEVIN
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MCGOVERN
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 1:291 RADIO AVE
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-3528
Mailing Address - Country:US
Mailing Address - Phone:631-278-9160
Mailing Address - Fax:718-777-5250
Practice Address - Street 1:2534 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3702
Practice Address - Country:US
Practice Address - Phone:718-777-5243
Practice Address - Fax:718-777-5250
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1277625923103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist