Provider Demographics
NPI:1134406887
Name:WAVERLY GROUP
Entity type:Organization
Organization Name:WAVERLY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZALIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:203-622-8600
Mailing Address - Street 1:100 MELROSE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6257
Mailing Address - Country:US
Mailing Address - Phone:203-622-8600
Mailing Address - Fax:203-622-1760
Practice Address - Street 1:100 MELROSE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6257
Practice Address - Country:US
Practice Address - Phone:203-622-8600
Practice Address - Fax:203-622-1760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CT001840103TC2200X
CT003422225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty