Provider Demographics
NPI:1235737495
Name:WIRTH, BRENNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:WIRTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412031
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2031
Mailing Address - Country:US
Mailing Address - Phone:888-830-4125
Mailing Address - Fax:
Practice Address - Street 1:1159 E M 21
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9037
Practice Address - Country:US
Practice Address - Phone:989-607-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013108225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist