Provider Demographics
NPI:1801313051
Name:MCGOVERN, MICHAEL JOESPEH (STUDENT AT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOESPEH
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:STUDENT AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 LONG LEAF DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1462
Mailing Address - Country:US
Mailing Address - Phone:321-213-3201
Mailing Address - Fax:
Practice Address - Street 1:4121 LONG LEAF DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1462
Practice Address - Country:US
Practice Address - Phone:321-213-3201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer