Provider Demographics
NPI:1689720302
Name:WESTSIDE BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:WESTSIDE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTENER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-580-4611
Mailing Address - Street 1:7 CHRISTY DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-580-4611
Mailing Address - Fax:508-580-4404
Practice Address - Street 1:7 CHRISTY DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-580-4611
Practice Address - Fax:508-580-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7330103T00000X
MA8177103T00000X
MA1050281041C0700X
MA1045901041C0700X
MA1107461041C0700X
MA10272001041C0700X
MA94523163WP0808X
MA90943163WP0808X
MA350812084P0800X
MA135140364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP10235OtherBLUE CROSS GROUP NUMBER
MAP10235OtherBLUE CROSS GROUP NUMBER
MAP10235OtherBLUE CROSS GROUP NUMBER