MEDICARE: DR. JOHN JOSEPH MCGOVERN LCSW, PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R028623	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R028623	OTHER	NY	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1316225832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN JOSEPH MCGOVERN LCSW, PH.D.

Provider Business Mailing Address
First Line	:	37 PRIMROSE LN
Second Line	:
City	:	KINGS PARK
State	:	NY
Zip	:	11754-3931
Country	:	US
Telephone Number	:	631-360-0172
Fax Number	:

Provider Business Practice Location Address
First Line	:	283 SPRINGS FIREPLACE RD
Second Line	:
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937-4823
Country	:	US
Telephone Number	:	631-329-0373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2011
Last Update Date	:	08/01/2011

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