Healthcare Provider Details

I. General information

NPI: 1689342479
Provider Name (Legal Business Name): REBEKAH WIRTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STEVENS ST SW
GRAND RAPIDS MI
49507-1526
US

IV. Provider business mailing address

4729 BRUSHWOOD BLVD SW UNIT 301
WYOMING MI
49418-8926
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 815-210-1749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: