Provider Demographics
NPI:1427451822
Name:MCGOVERN, BRIAN (BCBA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 IMPERIAL PL UNIT 3C
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4643
Mailing Address - Country:US
Mailing Address - Phone:401-523-1401
Mailing Address - Fax:
Practice Address - Street 1:18 IMPERIAL PL UNIT 3C
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4643
Practice Address - Country:US
Practice Address - Phone:401-523-1401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1-12-10129103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst