Provider Demographics
NPI:1932413887
Name:THE WAYSIDE HOUSE, INC.
Entity type:Organization
Organization Name:THE WAYSIDE HOUSE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-405-7649
Mailing Address - Street 1:1600 UNIVERSITY AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3800
Mailing Address - Country:US
Mailing Address - Phone:651-242-5540
Mailing Address - Fax:651-209-6341
Practice Address - Street 1:2120 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2649
Practice Address - Country:US
Practice Address - Phone:612-871-0099
Practice Address - Fax:612-871-0929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE WAYSIDE HOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-03
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1055132-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility