Healthcare Provider Details

I. General information

NPI: 1427462191
Provider Name (Legal Business Name): WIRTH COUNSELING SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19250 EVERETT LN SUITE #102
MOKENA IL
60448-8942
US

IV. Provider business mailing address

680 LENOX ST
NEW LENOX IL
60451-4200
US

V. Phone/Fax

Practice location:
  • Phone: 708-925-7258
  • Fax:
Mailing address:
  • Phone: 815-717-8575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009160
License Number StateIL

VIII. Authorized Official

Name: MRS. DENISE ANN WIRTH
Title or Position: PRESIDENT
Credential: LCPC
Phone: 708-925-7258