Provider Demographics
NPI:1417541178
Name:WURTZ, MARY LAVERN (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAVERN
Last Name:WURTZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LAVERN
Other - Last Name:LANSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1612 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1612 S COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3106
Practice Address - Country:US
Practice Address - Phone:208-507-8065
Practice Address - Fax:208-694-5909
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38736104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker