Provider Demographics
NPI:1023488640
Name:WIRTZ, EDITH
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:
Last Name:WIRTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:EDITH
Other - Middle Name:ADRIANA
Other - Last Name:WIRTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:113 PHEASANT TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-1240
Mailing Address - Country:US
Mailing Address - Phone:847-732-4591
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1948
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178008236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL721576970OtherTAXPAYER IDENTIFICATION NUMBER