Provider Demographics
NPI:1508582842
Name:WIRTH, CAROL ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ELLEN
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 1:47 KELSEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1109
Mailing Address - Country:US
Mailing Address - Phone:631-988-7316
Mailing Address - Fax:
Practice Address - Street 1:47 KELSEY AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11746-1109
Practice Address - Country:US
Practice Address - Phone:631-988-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0722611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty