Healthcare Provider Details

I. General information

NPI: 1225798770
Provider Name (Legal Business Name): MISS KYLE ALEXANDRA MACGOVERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 CHESTNUT ST STE 200
PROVIDENCE RI
02903-4604
US

IV. Provider business mailing address

171 CHESTNUT ST STE 200
PROVIDENCE RI
02903-4604
US

V. Phone/Fax

Practice location:
  • Phone: 401-756-1317
  • Fax:
Mailing address:
  • Phone: 401-756-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: