MEDICARE: STACIE WIRTH

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	373H00000X	Day Training/Habilitation Specialist
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1356188098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE WIRTH

Provider Business Mailing Address
First Line	:	5431 ELAINA CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-1765
Country	:	US
Telephone Number	:	702-354-3956
Fax Number	:

Provider Business Practice Location Address
First Line	:	5431 ELAINA CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-1765
Country	:	US
Telephone Number	:	702-354-3956
Fax Number	:

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

Provider Enumeration Date	:	07/10/2024
Last Update Date	:	06/04/2025

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Directions to “ STACIE WIRTH ” Practice Location

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