Provider Demographics
NPI:1437222171
Name:PONTIUS, MIKE JAY I
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:JAY
Last Name:PONTIUS
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:JAY
Other - Last Name:PONTIUS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 150521
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-0521
Mailing Address - Country:US
Mailing Address - Phone:616-437-6628
Mailing Address - Fax:616-336-2166
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-988-9388
Practice Address - Fax:616-732-6392
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006132101YP2500X
MI68010620981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical