Healthcare Provider Details

I. General information

NPI: 1003072497
Provider Name (Legal Business Name): JOANNE MARY WIRTZ MS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 S ROBINSON AVE
GREEN BAY WI
54311-5537
US

IV. Provider business mailing address

1275 S ROBINSON AVE
GREEN BAY WI
54311-5537
US

V. Phone/Fax

Practice location:
  • Phone: 920-737-3077
  • Fax:
Mailing address:
  • Phone: 920-737-3077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2841
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: