Provider Demographics
NPI:1730533340
Name:WONDERFULLY MADE SERVICES LLC
Entity type:Organization
Organization Name:WONDERFULLY MADE SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:757-344-6210
Mailing Address - Street 1:PO BOX 9364
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-0364
Mailing Address - Country:US
Mailing Address - Phone:747-344-6210
Mailing Address - Fax:855-612-7072
Practice Address - Street 1:12 BRAEMAR DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3706
Practice Address - Country:US
Practice Address - Phone:757-344-6210
Practice Address - Fax:855-612-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health