Provider Demographics
NPI:1518378645
Name:WIRTZ, BROOKE (LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WIRTZ
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 1:4480 N FORDNEY RD
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626-8460
Mailing Address - Country:US
Mailing Address - Phone:803-640-5383
Mailing Address - Fax:
Practice Address - Street 1:1500 WEISS ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5251
Practice Address - Country:US
Practice Address - Phone:989-497-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011046211041C0700X
NCC0088641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical