Healthcare Provider Details

I. General information

NPI: 1215133822
Provider Name (Legal Business Name): KEVIN BRUCE WURTZ LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3674
US

IV. Provider business mailing address

2061 SAN VICENTE AVE
LONG BEACH CA
90815-3259
US

V. Phone/Fax

Practice location:
  • Phone: 562-949-8455
  • Fax:
Mailing address:
  • Phone: 562-606-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 45098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: