Healthcare Provider Details

I. General information

NPI: 1154921989
Provider Name (Legal Business Name): THERAPY WONDERLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11628 SW 50TH CT
COOPER CITY FL
33330-4414
US

IV. Provider business mailing address

11628 SW 50TH CT
COOPER CITY FL
33330-4414
US

V. Phone/Fax

Practice location:
  • Phone: 305-335-3263
  • Fax:
Mailing address:
  • Phone: 305-335-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSICA MOULE
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 305-335-3263