Provider Demographics
NPI:1215133822
Name:WURTZ, KEVIN BRUCE (LMFT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRUCE
Last Name:WURTZ
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 SAN VICENTE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3259
Mailing Address - Country:US
Mailing Address - Phone:562-606-3885
Mailing Address - Fax:
Practice Address - Street 1:11721 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3674
Practice Address - Country:US
Practice Address - Phone:562-949-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45098106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist