Provider Demographics
NPI:1417541178
Name:WURTZ, MARY LAVERN (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LAVERN
Last Name:WURTZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LAVERN
Other - Last Name:LANSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:552 N MOONGLOW AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:552 N MOONGLOW AVE
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2295
Practice Address - Country:US
Practice Address - Phone:208-507-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-429101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical