Provider Demographics
NPI:1487226221
Name:SPEESE, RYAN (LMSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SPEESE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 ROYCE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4941
Mailing Address - Country:US
Mailing Address - Phone:269-491-3599
Mailing Address - Fax:
Practice Address - Street 1:614 ROMENCE RD STE 245
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3613
Practice Address - Country:US
Practice Address - Phone:269-615-7637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011051621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487226221Medicaid
MI1275885881Medicaid