Provider Demographics
NPI:1811543713
Name:BOYD, ELLISE JEANNETTE (MAED)
Entity Type:Individual
Prefix:
First Name:ELLISE
Middle Name:JEANNETTE
Last Name:BOYD
Suffix:
Gender:F
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RUBY ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6228
Mailing Address - Country:US
Mailing Address - Phone:708-510-1287
Mailing Address - Fax:
Practice Address - Street 1:300 RUBY ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6228
Practice Address - Country:US
Practice Address - Phone:708-510-1287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL549055172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL549055OtherFAMILY AND PARENTING SUPPORT SERVICES
IL549055OtherCHILD CARE INSTITUTION