Provider Demographics
NPI:1508407305
Name:BOYLAN, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BOYLAN
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 1:1800 NW 169TH PL STE B100
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7362
Mailing Address - Country:US
Mailing Address - Phone:503-350-7050
Mailing Address - Fax:
Practice Address - Street 1:1800 NW 169TH PL STE B100
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7362
Practice Address - Country:US
Practice Address - Phone:503-350-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst