Provider Demographics
NPI:1245873884
Name:RITCHIE, JONATHAN TYLER
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLER
Last Name:RITCHIE
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 1:1912 CONCORD AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4653
Mailing Address - Country:US
Mailing Address - Phone:616-638-6178
Mailing Address - Fax:
Practice Address - Street 1:1912 CONCORD AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4653
Practice Address - Country:US
Practice Address - Phone:616-638-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101003857235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist