Basic Information
| Provider Information | |||||||||
| NPI: | 1134406887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAVERLY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MELROSE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036228600 | ||||||||
| FaxNumber: | 2036221760 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MELROSE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036228600 | ||||||||
| FaxNumber: | 2036221760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZALIS | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2036228600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103TC2200X | 001840 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 225XP0200X | 003422 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.