Provider Demographics
NPI:1477032274
Name:EARLY WONDERS PEDIATRICS, LLC
Entity Type:Organization
Organization Name:EARLY WONDERS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BOGGIO
Authorized Official - Suffix:
Authorized Official - Credentials:MSOT, OTR/L
Authorized Official - Phone:618-205-6223
Mailing Address - Street 1:406 TERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1551
Mailing Address - Country:US
Mailing Address - Phone:618-205-6223
Mailing Address - Fax:
Practice Address - Street 1:406 TERRY DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1551
Practice Address - Country:US
Practice Address - Phone:618-205-6223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty