Provider Demographics
NPI:1992598999
Name:BOYD, MYCHELLE
Entity type:Individual
Prefix:
First Name:MYCHELLE
Middle Name:
Last Name:BOYD
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 MAPLELEAF CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-8075
Mailing Address - Country:US
Mailing Address - Phone:815-315-2077
Mailing Address - Fax:
Practice Address - Street 1:332 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4434
Practice Address - Country:US
Practice Address - Phone:133-951-0738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25-414107106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician