Provider Demographics
NPI:1376849844
Name:WIRTH, KATHERINE ROHRER (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROHRER
Last Name:WIRTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 UNION PACIFIC DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7626
Mailing Address - Country:US
Mailing Address - Phone:847-644-6717
Mailing Address - Fax:
Practice Address - Street 1:4203 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6164
Practice Address - Country:US
Practice Address - Phone:904-296-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 101581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 10158OtherLCSW