Provider Demographics
NPI:1104977131
Name:WAYSIDE YOUTH & FAMILY SUPPORT NETWORK
Entity type:Organization
Organization Name:WAYSIDE YOUTH & FAMILY SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HOME BASE PROGRAM
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:781-891-0556
Mailing Address - Street 1:22 PLEASANT ST
Mailing Address - Street 2:2205
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5119
Mailing Address - Country:US
Mailing Address - Phone:781-338-2640
Mailing Address - Fax:781-338-2217
Practice Address - Street 1:22 PLEASANT ST
Practice Address - Street 2:2205
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5119
Practice Address - Country:US
Practice Address - Phone:781-338-2640
Practice Address - Fax:781-338-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1043861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty