Provider Demographics
NPI:1417106717
Name:BOYD, JOHANNA NICOLE (MA)
Entity Type:Individual
Prefix:MISS
First Name:JOHANNA
Middle Name:NICOLE
Last Name:BOYD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 S MERIDIAN STE C223
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3603
Mailing Address - Country:US
Mailing Address - Phone:253-365-7290
Mailing Address - Fax:253-987-7223
Practice Address - Street 1:102 23RD AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4501
Practice Address - Country:US
Practice Address - Phone:253-365-7290
Practice Address - Fax:253-987-7223
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60117140106H00000X
WALF60247677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2140045Medicaid
1447811419OtherGROUP NPI