Provider Demographics
NPI:1043510175
Name:WIRTH, RICHARD W
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:W
Last Name:WIRTH
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 1:17 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2729
Mailing Address - Country:US
Mailing Address - Phone:631-673-3605
Mailing Address - Fax:
Practice Address - Street 1:807 SOUTH OYSTER BAY ROAD
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714
Practice Address - Country:US
Practice Address - Phone:516-822-0028
Practice Address - Fax:516-822-4113
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003663-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist