Provider Demographics
NPI:1235223652
Name:THE WAYSIDE HOUSE, INC
Entity Type:Organization
Organization Name:THE WAYSIDE HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:952-926-5626
Mailing Address - Street 1:3705 PARK CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2504
Mailing Address - Country:US
Mailing Address - Phone:952-926-5626
Mailing Address - Fax:952-926-9713
Practice Address - Street 1:3705 PARK CENTER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2504
Practice Address - Country:US
Practice Address - Phone:952-926-5626
Practice Address - Fax:952-926-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN802632-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN389255700Medicaid