Healthcare Provider Details

I. General information

NPI: 1518371657
Provider Name (Legal Business Name): WINGS TO FLY THERAPY AND PLAY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 WALNEY ROAD SUITE 203
CHANTILLY VA
20151
US

IV. Provider business mailing address

4530 WALNEY ROAD SUITE 203
CHANTILLY VA
20151
US

V. Phone/Fax

Practice location:
  • Phone: 703-466-5533
  • Fax: 703-466-5533
Mailing address:
  • Phone: 703-466-5533
  • Fax: 703-466-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateVA

VIII. Authorized Official

Name: DONNA SHANK
Title or Position: OWNER/DIRECTOR
Credential: M.A.
Phone: 703-466-5533