Provider Demographics
NPI:1235295155
Name:WANDERS, MICHAEL (LSW,LADC1)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WANDERS
Suffix:
Gender:M
Credentials:LSW,LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1408
Mailing Address - Country:US
Mailing Address - Phone:508-376-8380
Mailing Address - Fax:
Practice Address - Street 1:1881 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-5410
Practice Address - Country:US
Practice Address - Phone:508-872-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1199101YA0400X
MA3032220104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker