Provider Demographics
NPI:1871800292
Name:WIRTZ, HOLLY (PT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WIRTZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3048 E BASELINE RD
Practice Address - Street 2:SUITE 125
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7286
Practice Address - Country:US
Practice Address - Phone:480-222-0655
Practice Address - Fax:480-222-1457
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8930225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ645714Medicaid
AZZ148609Medicare PIN