Provider Demographics
NPI:1790188100
Name:WIRTH, KIMBERLY (MSW,LSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WIRTH
Suffix:
Gender:F
Credentials:MSW,LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:2615 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3915
Practice Address - Country:US
Practice Address - Phone:618-462-2331
Practice Address - Fax:618-462-2504
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.113301104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker