Healthcare Provider Details

I. General information

NPI: 1629362769
Provider Name (Legal Business Name): LYNAIRE MCGOVERN LMFT-LICENSED MARRIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5332 COLLEGE AVE # 205
OAKLAND CA
94518-2226
US

IV. Provider business mailing address

1727 DALESSI DR
PINOLE CA
94564-2226
US

V. Phone/Fax

Practice location:
  • Phone: 510-470-0063
  • Fax:
Mailing address:
  • Phone: 510-451-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number450
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTI 57794
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number#52148
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number52148
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: