Provider Demographics
NPI:1518689835
Name:WONDERLY, LAUREN ELISE (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELISE
Last Name:WONDERLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 RANCH ROAD 12
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-2435
Mailing Address - Country:US
Mailing Address - Phone:512-557-6664
Mailing Address - Fax:
Practice Address - Street 1:13915 BURNET RD STE 204
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6537
Practice Address - Country:US
Practice Address - Phone:817-505-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist