Provider Demographics
NPI:1598109134
Name:WIRTH, PAUL (CERT ROLFER, LMT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WIRTH
Suffix:
Gender:M
Credentials:CERT ROLFER, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S 900 E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2490
Mailing Address - Country:US
Mailing Address - Phone:801-638-0021
Mailing Address - Fax:
Practice Address - Street 1:311 S 900 E
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2490
Practice Address - Country:US
Practice Address - Phone:801-638-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5587521225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5587521-4701OtherMASSAGE THERAPIST LICENSE
401155-00OtherNATIONAL CERTIFICATION BOARD FOR THERAPEUTIC MASSAGE AND BODYWORK