Healthcare Provider Details

I. General information

NPI: 1952213605
Provider Name (Legal Business Name): WONDERFULLY MADE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 NORTHGATE DR
LAUREL MS
39440-2119
US

IV. Provider business mailing address

12 NORTHGATE DR
LAUREL MS
39440-2119
US

V. Phone/Fax

Practice location:
  • Phone: 601-498-7248
  • Fax:
Mailing address:
  • Phone: 601-498-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARY SURRETT
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 601-498-7248