Provider Demographics
NPI:1316469760
Name:BOYD, EVERT RAY (LP MSE)
Entity type:Individual
Prefix:MR
First Name:EVERT
Middle Name:RAY
Last Name:BOYD
Suffix:
Gender:M
Credentials:LP MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 HIGHWAY 100 S.
Mailing Address - Street 2:GROVES ACADEMY
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-920-6377
Mailing Address - Fax:952-920-2068
Practice Address - Street 1:3200 HIGHWAY 100 S.
Practice Address - Street 2:GROVES ACADEMY
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-920-6377
Practice Address - Fax:952-920-2068
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1736103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool