Provider Demographics
NPI:1215667043
Name:BOYD, MICHELLE MARIE (R1470860622)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:BOYD
Suffix:
Gender:F
Credentials:R1470860622
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-0586
Mailing Address - Country:US
Mailing Address - Phone:530-644-3758
Mailing Address - Fax:530-644-2031
Practice Address - Street 1:5494 PONY EXPRESS TRL
Practice Address - Street 2:
Practice Address - City:CAMINO
Practice Address - State:CA
Practice Address - Zip Code:95709
Practice Address - Country:US
Practice Address - Phone:530-644-3758
Practice Address - Fax:530-644-2031
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1470860622101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)