Provider Demographics
NPI:1265815591
Name:BOYKIN-LIGHTON, MYRTLE
Entity Type:Individual
Prefix:
First Name:MYRTLE
Middle Name:
Last Name:BOYKIN-LIGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1054
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:419-222-7044
Practice Address - Street 1:809 W VINE ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1054
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 247ZC0005X
OH0782405300000X
OH1163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341741132Medicaid
OH3417411132Medicare NSC
OH341741132Medicaid
OH341741132Medicare PIN
OH341741132Medicare UPIN