Provider Demographics
NPI:1073983003
Name:WONDERLY, MCCAULLEY
Entity Type:Individual
Prefix:
First Name:MCCAULLEY
Middle Name:
Last Name:WONDERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W FRANKLIN ST
Mailing Address - Street 2:APARTMENT 1904
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4965
Mailing Address - Country:US
Mailing Address - Phone:703-258-9457
Mailing Address - Fax:
Practice Address - Street 1:11240 WAPLES MILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6078
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-15-02150103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst