Provider Demographics
NPI:1013422849
Name:WIRTH, JOHN (MS, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WIRTH
Suffix:
Gender:M
Credentials:MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 OLD SOLOMONS ISLAND RD STE 202
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3879
Mailing Address - Country:US
Mailing Address - Phone:410-266-3058
Mailing Address - Fax:
Practice Address - Street 1:102 OLD SOLOMONS ISLAND RD STE 202
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3879
Practice Address - Country:US
Practice Address - Phone:410-266-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10123101YM0800X
MDLC7065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health