1215189659 NPI number — BRIAN THOMAS MCGOVERN MSW, LCSW

Table of content: BRIAN THOMAS MCGOVERN MSW, LCSW (NPI 1215189659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215189659 NPI number — BRIAN THOMAS MCGOVERN MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGOVERN
Provider First Name:
BRIAN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215189659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 MAIN ST
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DEPARTMENT
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-347-6971
Provider Business Mailing Address Fax Number:
860-638-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 MATHER ST
Provider Second Line Business Practice Location Address:
UNIT 132
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06514-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-685-7556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004236346 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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