Basic Information
| Provider Information | |||||||||
| NPI: | 1871800292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIRTZ | ||||||||
| FirstName: | HOLLY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6570 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853856570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233988072 | ||||||||
| FaxNumber: | 6233988235 | ||||||||
| Practice Location | |||||||||
| Address1: | 3048 E BASELINE RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852047286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802220655 | ||||||||
| FaxNumber: | 4802221457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8930 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 645714 | 05 | AZ | MEDICAID |