Healthcare Provider Details

I. General information

NPI: 1295012334
Provider Name (Legal Business Name): KATHERINE MARIE WURTZ ATC, ATR, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE THERAPY DEPARTMENT
DETROIT LAKES MN
56501
US

IV. Provider business mailing address

1027 WASHINGTON AVE THERAPY DEPARTMENT
DETROIT LAKES MN
56501-3409
US

V. Phone/Fax

Practice location:
  • Phone: 701-898-0668
  • Fax:
Mailing address:
  • Phone: 218-847-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2309
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number421-11
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: