Provider Demographics
NPI:1720633951
Name:WONDERLIGHT THERAPY LLC
Entity Type:Organization
Organization Name:WONDERLIGHT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST, CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKUIPER
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:615-294-3084
Mailing Address - Street 1:116 VILLA VIEW CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3919
Mailing Address - Country:US
Mailing Address - Phone:615-294-3084
Mailing Address - Fax:
Practice Address - Street 1:116 VILLA VIEW CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3919
Practice Address - Country:US
Practice Address - Phone:615-294-3084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty