Provider Demographics
NPI:1124580667
Name:BOYLAN, JOHN (COTA MFDC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:BOYLAN
Suffix:
Gender:M
Credentials:COTA MFDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ACCIDENT BITTINGER RD
Mailing Address - Street 2:
Mailing Address - City:ACCIDENT
Mailing Address - State:MD
Mailing Address - Zip Code:21520-1312
Mailing Address - Country:US
Mailing Address - Phone:540-359-1985
Mailing Address - Fax:
Practice Address - Street 1:116 ACCIDENT BITTINGER RD
Practice Address - Street 2:
Practice Address - City:ACCIDENT
Practice Address - State:MD
Practice Address - Zip Code:21520-1312
Practice Address - Country:US
Practice Address - Phone:540-359-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4796224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant