MEDICARE: MRS. ABBY WIRICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1235525189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABBY WIRICK

Provider Business Mailing Address
First Line	:	9168 LAKE FISCHER BLVD
Second Line	:
City	:	GOTHA
State	:	FL
Zip	:	34734-5201
Country	:	US
Telephone Number	:	407-415-0222
Fax Number	:

Provider Business Practice Location Address
First Line	:	9168 LAKE FISCHER BLVD
Second Line	:
City	:	GOTHA
State	:	FL
Zip	:	34734-5201
Country	:	US
Telephone Number	:	407-415-0222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2015
Last Update Date	:	04/07/2015

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