Provider Demographics
NPI:1548034309
Name:WIRT, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WIRT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:MARIE
Other - Last Name:WIRT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1228 VERMEER DR
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-4439
Mailing Address - Country:US
Mailing Address - Phone:941-929-8199
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:185-583-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician