Provider Demographics
NPI:1114300696
Name:BOYD, MARY LEE (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY LEE
Middle Name:
Last Name:BOYD
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 1:2207 PONTIAC DR
Mailing Address - Street 2:
Mailing Address - City:SYLVAN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1767
Mailing Address - Country:US
Mailing Address - Phone:248-514-2684
Mailing Address - Fax:
Practice Address - Street 1:3186 SUMMERS RD
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1372
Practice Address - Country:US
Practice Address - Phone:248-383-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI728812225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist