Provider Demographics
NPI:1972295871
Name:MCGOVERN, MALLORY R
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:R
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 1:9427 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1134
Mailing Address - Country:US
Mailing Address - Phone:708-267-9960
Mailing Address - Fax:
Practice Address - Street 1:833 W CHICAGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5449
Practice Address - Country:US
Practice Address - Phone:847-494-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.006856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist