Healthcare Provider Details

I. General information

NPI: 1306493739
Provider Name (Legal Business Name): AMY LYNN WIRTZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMYL LYNN CROSSMAN

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 NW CORNELL RD
PORTLAND OR
97229-5442
US

IV. Provider business mailing address

14600 NW CORNELL RD
PORTLAND OR
97229-5442
US

V. Phone/Fax

Practice location:
  • Phone: 503-645-3581
  • Fax:
Mailing address:
  • Phone: 503-645-3581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: