Provider Demographics
NPI:1477863090
Name:BOYD, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BOYD
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 1:124 W POLK ST APT 805
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1767
Mailing Address - Country:US
Mailing Address - Phone:312-351-0782
Mailing Address - Fax:
Practice Address - Street 1:124 W POLK ST APT 805
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1767
Practice Address - Country:US
Practice Address - Phone:312-351-0782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-16
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004308225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056004308OtherILLINOIS