Provider Demographics
NPI:1568406841
Name:BOYLES, MISTY DAWN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DAWN
Last Name:BOYLES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 STELLA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2170
Mailing Address - Country:US
Mailing Address - Phone:719-488-1324
Mailing Address - Fax:719-487-8415
Practice Address - Street 1:1604 STELLA DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-2170
Practice Address - Country:US
Practice Address - Phone:719-488-1324
Practice Address - Fax:719-487-8415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37701541Medicaid