Provider Demographics
NPI:1699264499
Name:WIRTZ, KRISTINE (RBT-18-54764)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:
Last Name:WIRTZ
Suffix:
Gender:F
Credentials:RBT-18-54764
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60146-8803
Mailing Address - Country:US
Mailing Address - Phone:630-273-1061
Mailing Address - Fax:
Practice Address - Street 1:113 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:IL
Practice Address - Zip Code:60146-8803
Practice Address - Country:US
Practice Address - Phone:630-273-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-54764106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician