Provider Demographics
NPI:1548757339
Name:WIRTH, JEREMIAH STUART (LCSW)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:STUART
Last Name:WIRTH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-303-2906
Mailing Address - Fax:407-303-7126
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-2906
Practice Address - Fax:407-303-7126
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW150051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical