Provider Demographics
NPI:1548038961
Name:MCGOVERN, BRENNA ROSE (DPT)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:ROSE
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 JEFFREY DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-5637
Mailing Address - Country:US
Mailing Address - Phone:607-768-6903
Mailing Address - Fax:
Practice Address - Street 1:9 HAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4832
Practice Address - Country:US
Practice Address - Phone:802-775-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216202225100000X
VT040-0134803225100000X
NY050886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist