Provider Demographics
NPI:1881601391
Name:WIRTH, MARY THERESA (OTR)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:WIRTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40640 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-8736
Mailing Address - Country:US
Mailing Address - Phone:847-395-9270
Mailing Address - Fax:847-395-9272
Practice Address - Street 1:40640 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-8736
Practice Address - Country:US
Practice Address - Phone:847-395-9270
Practice Address - Fax:847-395-9272
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist