Provider Demographics
NPI:1255823092
Name:MCGOVERN, DYLAN J
Entity type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:J
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 1:4900 REBECCA BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3246
Mailing Address - Country:US
Mailing Address - Phone:504-201-2521
Mailing Address - Fax:
Practice Address - Street 1:4900 REBECCA BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3246
Practice Address - Country:US
Practice Address - Phone:504-201-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician