Healthcare Provider Details

I. General information

NPI: 1396658506
Provider Name (Legal Business Name): ROY C WIRTZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62445 SHIMMEL RD
CENTREVILLE MI
49032-9527
US

IV. Provider business mailing address

62445 SHIMMEL RD
CENTREVILLE MI
49032-9527
US

V. Phone/Fax

Practice location:
  • Phone: 269-467-5400
  • Fax:
Mailing address:
  • Phone: 574-261-6933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801060774
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: