Provider Demographics
NPI:1154829042
Name:WIRTH, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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:REBEKAH CHILDRENS SERVICES
Mailing Address - Street 2:290 IOOF AVE
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:REBEKAH CHILDRENS SERVICES
Practice Address - Street 2:290 IOOF AVE
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020
Practice Address - Country:US
Practice Address - Phone:408-846-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health