Provider Demographics
NPI:1891854105
Name:WEISS, WENDY E (MSW,LICSW)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:E
Last Name:WEISS
Suffix:
Gender:F
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2661
Mailing Address - Country:US
Mailing Address - Phone:413-237-2430
Mailing Address - Fax:
Practice Address - Street 1:175 DWIGHT RD
Practice Address - Street 2:SUITE 303
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1761
Practice Address - Country:US
Practice Address - Phone:413-567-9993
Practice Address - Fax:413-567-9993
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110391104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23522Medicare ID - Type Unspecified