Provider Demographics
NPI:1417480195
Name:BOYD, SAMUEL HENRY JR (LSW, LICDC-CS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:HENRY
Last Name:BOYD
Suffix:JR
Gender:M
Credentials:LSW, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 KENNY RD.
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221
Mailing Address - Country:US
Mailing Address - Phone:614-685-2730
Mailing Address - Fax:614-293-9502
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:SUITE 3300
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-685-2730
Practice Address - Fax:614-293-9502
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH965723101YA0400X
OHS-0015831104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101YA0400XMedicaid
OH101Y60000XMedicaid
OH104100000XMedicaid