Provider Demographics
NPI:1023474277
Name:BOYLAN, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOYLAN
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 1:414 S BURDICK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-6219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 S BURDICK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-6219
Practice Address - Country:US
Practice Address - Phone:269-381-4446
Practice Address - Fax:269-381-4457
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088366104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker