Provider Demographics
NPI:1174012330
Name:BOYD, JUSTIN MICHAEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:BOYD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 AMERICAN WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6117
Mailing Address - Country:US
Mailing Address - Phone:318-841-0696
Mailing Address - Fax:318-841-0776
Practice Address - Street 1:727 AMERICAN WAY STE 2
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6117
Practice Address - Country:US
Practice Address - Phone:318-841-0696
Practice Address - Fax:318-841-0776
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09895OtherPHYSICAL THERAPY