Provider Demographics
NPI:1790063725
Name:BOYD, DIANE SUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:SUE
Last Name:BOYD
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 1:5896 DIXIE HWY
Mailing Address - Street 2:STE B
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-461-6674
Mailing Address - Fax:248-461-6594
Practice Address - Street 1:5896 DIXIE HWY
Practice Address - Street 2:STE B
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-461-6674
Practice Address - Fax:248-461-6594
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003984225100000X
MI5501003156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist