Provider Demographics
NPI:1932512902
Name:WIRTH, DENISE A (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:A
Last Name:WIRTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 LENOX ST
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-4200
Mailing Address - Country:US
Mailing Address - Phone:708-925-7258
Mailing Address - Fax:
Practice Address - Street 1:19250 EVERETT LN
Practice Address - Street 2:SUITE #102
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8942
Practice Address - Country:US
Practice Address - Phone:708-925-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional