MEDICARE: DR. RONALD HAROLD BOARDWAY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	RB008826	MI

General Provider Information

NPI Number	:	1881703858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD HAROLD BOARDWAY PHD

Provider Business Mailing Address
First Line	:	19900 E 10 MILE RD STE 102
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-776-3666
Fax Number	:	586-776-3369

Provider Business Practice Location Address
First Line	:	19900 E 10 MILE RD STE 102
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-776-3666
Fax Number	:	586-776-3369

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	06/05/2019

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