Provider Demographics
NPI:1427134584
Name:MCGOVERN, MAVERICK (LPA)
Entity type:Individual
Prefix:MR
First Name:MAVERICK
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NC
Mailing Address - Zip Code:28127-6608
Mailing Address - Country:US
Mailing Address - Phone:336-302-3444
Mailing Address - Fax:
Practice Address - Street 1:1252 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NC
Practice Address - Zip Code:28127-6608
Practice Address - Country:US
Practice Address - Phone:336-302-3444
Practice Address - Fax:336-302-3444
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0835103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107459Medicaid