Healthcare Provider Details

I. General information

NPI: 1518689835
Provider Name (Legal Business Name): LAUREN ELISE WONDERLY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13915 BURNET RD STE 204
AUSTIN TX
78728-6537
US

IV. Provider business mailing address

2309 RANCH ROAD 12
SAN MARCOS TX
78666-2435
US

V. Phone/Fax

Practice location:
  • Phone: 817-505-2575
  • Fax:
Mailing address:
  • Phone: 512-557-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: