Provider Demographics
NPI:1235536244
Name:WONNIE, MIRIAM (M ED,BSL)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:WONNIE
Suffix:
Gender:F
Credentials:M ED,BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MONTELLO RD
Mailing Address - Street 2:
Mailing Address - City:SINKING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:19608-1515
Mailing Address - Country:US
Mailing Address - Phone:610-927-4249
Mailing Address - Fax:
Practice Address - Street 1:ONE WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522
Practice Address - Country:US
Practice Address - Phone:610-944-0445
Practice Address - Fax:610-944-1196
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001706103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1083756902OtherCONCERN PROFESSIONAL SERVICES FOR CHILDREN , YOUTH, & FAMILIES