Provider Demographics
NPI:1790458024
Name:WIRTH, CHRISTIAN THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:THOMAS
Last Name:WIRTH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WESTLAND AVE UNIT 201
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-4563
Mailing Address - Country:US
Mailing Address - Phone:908-892-1103
Mailing Address - Fax:
Practice Address - Street 1:800 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02199-1900
Practice Address - Country:US
Practice Address - Phone:617-536-1161
Practice Address - Fax:844-912-8607
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25568225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist