Basic Information
| Provider Information | |||||||||
| NPI: | 1518378645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTZ | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4480 N FORDNEY RD | ||||||||
| Address2: | |||||||||
| City: | HEMLOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486268460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036405383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2014 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801104621 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C008864 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.