Provider Demographics
NPI:1043665011
Name:MUTCHNICK, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MUTCHNICK
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 1:801 W ANN ARBOR TRL
Mailing Address - Street 2:STE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1694
Mailing Address - Country:US
Mailing Address - Phone:734-354-8000
Mailing Address - Fax:
Practice Address - Street 1:801 W ANN ARBOR TRL
Practice Address - Street 2:STE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1694
Practice Address - Country:US
Practice Address - Phone:734-354-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14113707235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist