Provider Demographics
NPI:1558128702
Name:WIRTH, ELIZABETH RAE
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RAE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4500
Mailing Address - Country:US
Mailing Address - Phone:916-484-3570
Mailing Address - Fax:916-484-3577
Practice Address - Street 1:900 FULTON AVE STE 205
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4517
Practice Address - Country:US
Practice Address - Phone:916-484-3570
Practice Address - Fax:916-484-3577
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-OJSYXP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist