Provider Demographics
NPI:1982779948
Name:WONDERLAND DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:WONDERLAND DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIRCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-364-3777
Mailing Address - Street 1:PO BOX 55399
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155
Mailing Address - Country:US
Mailing Address - Phone:206-364-3777
Mailing Address - Fax:206-364-3999
Practice Address - Street 1:816 N E 190TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155
Practice Address - Country:US
Practice Address - Phone:206-364-3777
Practice Address - Fax:206-364-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 000044381041C0700X
WAOT00000540225X00000X
WAOT60282093225X00000X
WALL00003297235Z00000X
WASI 60251616235Z00000X
WALL 00004312235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7682651Medicaid
WA7300965Medicaid