Provider Demographics
NPI:1922262716
Name:RICHARDSON, JULIE RENAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:RENAE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5721
Mailing Address - Country:US
Mailing Address - Phone:616-451-2069
Mailing Address - Fax:616-451-4479
Practice Address - Street 1:515 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5721
Practice Address - Country:US
Practice Address - Phone:616-451-2069
Practice Address - Fax:616-451-4479
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist