Provider Demographics
NPI:1205929700
Name:WIRTH, DUANE LEROY (LADC)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:LEROY
Last Name:WIRTH
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:NE
Mailing Address - Zip Code:69357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 AVE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361
Practice Address - Country:US
Practice Address - Phone:308-635-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE528101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)