MEDICARE: WONDERFULLY MADE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1275806549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDERFULLY MADE

Provider Business Mailing Address
First Line	:	4559 SPARWOOD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8212
Country	:	US
Telephone Number	:	702-994-1931
Fax Number	:

Provider Business Practice Location Address
First Line	:	4559 SPARWOOD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8212
Country	:	US
Telephone Number	:	702-994-1931
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHERITA THOMAS-MCDADE
Credential	:	LSW
Telephone Number	:	702-994-1931

Provider Enumeration Date	:	02/17/2012
Last Update Date	:	02/17/2012

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Directions to “WONDERFULLY MADE ” Practice Location

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