Provider Demographics
NPI:1518371657
Name:WINGS TO FLY THERAPY AND PLAY CENTER
Entity Type:Organization
Organization Name:WINGS TO FLY THERAPY AND PLAY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:703-466-5533
Mailing Address - Street 1:4530 WALNEY ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151
Mailing Address - Country:US
Mailing Address - Phone:703-466-5533
Mailing Address - Fax:703-466-5533
Practice Address - Street 1:4530 WALNEY ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151
Practice Address - Country:US
Practice Address - Phone:703-466-5533
Practice Address - Fax:703-466-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208000000X, 225XP0200X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty