Provider Demographics
NPI:1679314348
Name:WIRTH, AMBER MICHELE (MA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MICHELE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 WATERTOWN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1800
Mailing Address - Country:US
Mailing Address - Phone:262-782-1474
Mailing Address - Fax:
Practice Address - Street 1:20700 WATERTOWN RD STE 102
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:262-782-1474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI787-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist