Provider Demographics
NPI:1740823228
Name:GOVAN, TARA L (LCAS 1917)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GOVAN
Suffix:
Gender:F
Credentials:LCAS 1917
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:GOVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:209 MARTIN LUTHER KING JR. DR.
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-7770
Mailing Address - Country:US
Mailing Address - Phone:910-247-6822
Mailing Address - Fax:910-247-6829
Practice Address - Street 1:209 MARTIN LUTHER KING JR. DR.
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-2833
Practice Address - Country:US
Practice Address - Phone:910-247-6822
Practice Address - Fax:910-247-6829
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)