Provider Demographics
NPI:1710688460
Name:WIRICK, ROBERT (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WIRICK
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E OHIO ST
Mailing Address - Street 2:
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-1741
Mailing Address - Country:US
Mailing Address - Phone:269-689-8055
Mailing Address - Fax:
Practice Address - Street 1:118 E OHIO ST
Practice Address - Street 2:
Practice Address - City:MOMENCE
Practice Address - State:IL
Practice Address - Zip Code:60954-1741
Practice Address - Country:US
Practice Address - Phone:269-689-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026886363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health