Basic Information
| Provider Information | |||||||||
| NPI: | 1639579154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTZ | ||||||||
| FirstName: | MOLLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 SPRUCE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 S COLUMBIAN WAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981081565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067622394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2014 | ||||||||
| LastUpdateDate: | 09/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60344737 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.