Provider Demographics
NPI:1518753045
Name:BOYDSTUN, TANNER BROCK
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:BROCK
Last Name:BOYDSTUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SPORTFISHER DRIVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054
Mailing Address - Country:US
Mailing Address - Phone:760-439-6702
Mailing Address - Fax:760-439-4779
Practice Address - Street 1:1100 SPORTFISHER DRIVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054
Practice Address - Country:US
Practice Address - Phone:760-439-6702
Practice Address - Fax:760-439-4779
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)