Provider Demographics
NPI:1942549258
Name:WIRTZ, TAMARA S (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:WIRTZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8738
Mailing Address - Country:US
Mailing Address - Phone:605-791-7400
Mailing Address - Fax:605-791-7401
Practice Address - Street 1:7110 JORDAN DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8738
Practice Address - Country:US
Practice Address - Phone:605-791-7400
Practice Address - Fax:605-791-7401
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12128886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist