Healthcare Provider Details

I. General information

NPI: 1568835239
Provider Name (Legal Business Name): LAURA WIRTH M.S. , CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14595 E RIDER RIDGE PL
VAIL AZ
85641-1604
US

IV. Provider business mailing address

14595 E RIDER RIDGE PL
VAIL AZ
85641-1604
US

V. Phone/Fax

Practice location:
  • Phone: 402-415-3749
  • Fax:
Mailing address:
  • Phone: 402-415-3749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP12762
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: