Healthcare Provider Details

I. General information

NPI: 1154822831
Provider Name (Legal Business Name): PAUL BRYAN WURTSMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3754 BRIAR CREEK LN
AMMON ID
83406-4688
US

IV. Provider business mailing address

3754 BRIAR CREEK LN
AMMON ID
83406-4688
US

V. Phone/Fax

Practice location:
  • Phone: 360-831-7425
  • Fax:
Mailing address:
  • Phone: 360-831-7425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-37202
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: