Healthcare Provider Details

I. General information

NPI: 1902089691
Provider Name (Legal Business Name): JONATHAN RICHARDSON PCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15705 GREENDALE RD
MAPLE HEIGHTS OH
44137-3717
US

IV. Provider business mailing address

15705 GREENDALE RD
MAPLE HEIGHTS OH
44137-3717
US

V. Phone/Fax

Practice location:
  • Phone: 216-587-3460
  • Fax:
Mailing address:
  • Phone: 216-587-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE0500069
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: