Provider Demographics
NPI:1275806549
Name:WONDERFULLY MADE
Entity Type:Organization
Organization Name:WONDERFULLY MADE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERITA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS-MCDADE
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:702-994-1931
Mailing Address - Street 1:4559 SPARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8212
Mailing Address - Country:US
Mailing Address - Phone:702-994-1931
Mailing Address - Fax:
Practice Address - Street 1:4559 SPARWOOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8212
Practice Address - Country:US
Practice Address - Phone:702-994-1931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty