Healthcare Provider Details

I. General information

NPI: 1740608751
Provider Name (Legal Business Name): EDWARD PAUL MCGOVERN III LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 MESA ST SE
ALBUQUERQUE NM
87106-4080
US

IV. Provider business mailing address

126 MESA ST SE
ALBUQUERQUE NM
87106-4080
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-5917
  • Fax:
Mailing address:
  • Phone: 505-577-5917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0164291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: