Provider Demographics
NPI:1376955997
Name:MACGOVERN, LISA MARY (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:MACGOVERN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 VINING CT
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-6658
Mailing Address - Country:US
Mailing Address - Phone:386-673-1041
Mailing Address - Fax:
Practice Address - Street 1:55 VINING CT APT 113
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-6676
Practice Address - Country:US
Practice Address - Phone:386-673-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35780225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist