Provider Demographics
NPI:1619588696
Name:BOYLE, TESSA
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:BOYLE
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 1:615 HEATH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2160
Mailing Address - Country:US
Mailing Address - Phone:570-902-5375
Mailing Address - Fax:
Practice Address - Street 1:1145 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1025
Practice Address - Country:US
Practice Address - Phone:207-541-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA605939235Z00000X
MESP3390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESP3390OtherSTATE OF MAINE