Provider Demographics
NPI:1639635980
Name:WAYSIDE HOUSE, INC.
Entity Type:Organization
Organization Name:WAYSIDE HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-666-9154
Mailing Address - Street 1:378 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483
Mailing Address - Country:US
Mailing Address - Phone:561-666-9168
Mailing Address - Fax:561-294-0178
Practice Address - Street 1:328 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-5517
Practice Address - Country:US
Practice Address - Phone:561-666-9154
Practice Address - Fax:561-294-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103939900Medicaid