Provider Demographics
NPI:1356219794
Name:BOYD, EBONI
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:BOYD
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 1:1437 HENDERSON RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3355
Mailing Address - Country:US
Mailing Address - Phone:910-476-4830
Mailing Address - Fax:
Practice Address - Street 1:3111 N TUSTIN ST STE 180
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1752
Practice Address - Country:US
Practice Address - Phone:714-282-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist