Healthcare Provider Details

I. General information

NPI: 1104977131
Provider Name (Legal Business Name): WAYSIDE YOUTH & FAMILY SUPPORT NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 PLEASANT ST 2205
MALDEN MA
02148-5119
US

IV. Provider business mailing address

22 PLEASANT ST 2205
MALDEN MA
02148-5119
US

V. Phone/Fax

Practice location:
  • Phone: 781-338-2640
  • Fax: 781-338-2217
Mailing address:
  • Phone: 781-338-2640
  • Fax: 781-338-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104386
License Number StateMA

VIII. Authorized Official

Name: MS. ANDREA SALZMAN
Title or Position: DIRECTOR OF HOME BASE PROGRAM
Credential: LICSW
Phone: 781-891-0556