Healthcare Provider Details

I. General information

NPI: 1629465810
Provider Name (Legal Business Name): STEWART M WURTZ LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 04/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 DEERPATH DR
LINDENHURST IL
60046-7805
US

IV. Provider business mailing address

2413 DEERPATH DR
LINDENHURST IL
60046-7805
US

V. Phone/Fax

Practice location:
  • Phone: 847-691-7443
  • Fax:
Mailing address:
  • Phone: 847-691-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.000739
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1182-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: