Provider Demographics
NPI:1346594991
Name:WIRT, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WIRT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1804 CENTRE POINT CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1440
Mailing Address - Country:US
Mailing Address - Phone:630-955-1940
Mailing Address - Fax:
Practice Address - Street 1:1804 CENTRE POINT CIR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1440
Practice Address - Country:US
Practice Address - Phone:630-955-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009945225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist