Provider Demographics
NPI:1053760652
Name:MCGOVERN, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 IBIS LANE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503
Mailing Address - Country:US
Mailing Address - Phone:775-525-4072
Mailing Address - Fax:
Practice Address - Street 1:659 IBIS LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-3925
Practice Address - Country:US
Practice Address - Phone:775-525-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0000060858171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator