MEDICARE: WONDERLAND PEDIATRIC THERAPY

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	225XP0200X	Pediatric Occupational Therapist

General Provider Information

NPI Number	:	1942098132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDERLAND PEDIATRIC THERAPY

Provider Business Mailing Address
First Line	:	146 MARRON DR
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-4510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10720 SIKES PL STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-8142
Country	:	US
Telephone Number	:	980-469-8109
Fax Number	:	704-973-9219

Authorized Official
Title or Position	:	OWNER, OT ASSISTANT
Name	:	JENNIFER MARIE FITZGERALD
Credential	:	BA, COTA/L
Telephone Number	:	732-691-2212

Provider Enumeration Date	:	04/28/2025
Last Update Date	:	04/28/2025

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Directions to “WONDERLAND PEDIATRIC THERAPY ” Practice Location

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