Provider Demographics
NPI:1053201939
Name:WIRT, MAKAYLA ALICE
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:ALICE
Last Name:WIRT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 W ANDALUSIAN TRL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8646
Mailing Address - Country:US
Mailing Address - Phone:480-531-4641
Mailing Address - Fax:
Practice Address - Street 1:5815 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009917225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist