Healthcare Provider Details

I. General information

NPI: 1992873830
Provider Name (Legal Business Name): DEBORAH ANN WIRTH MS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 5TH STREET SUITE O
SANTA FE NM
87505
US

IV. Provider business mailing address

19 VISTA CHICOMA RD
SANTA FE NM
87506
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-2176
  • Fax: 505-820-9811
Mailing address:
  • Phone: 505-820-6544
  • Fax: 505-820-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0185
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: