Provider Demographics
NPI:1578937454
Name:BOYLAN, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOYLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12250 SW 2ND ST STE A-102
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2828
Mailing Address - Country:US
Mailing Address - Phone:503-218-3754
Mailing Address - Fax:
Practice Address - Street 1:12250 SW 2ND ST STE A-102
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2828
Practice Address - Country:US
Practice Address - Phone:503-218-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5789106H00000X
372600000X
ORC6909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC6909OtherOREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS