Provider Demographics
NPI:1942423165
Name:WAYSIDE YOUTH AND FAMILY SUPPORT NETWROK
Entity Type:Organization
Organization Name:WAYSIDE YOUTH AND FAMILY SUPPORT NETWROK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:YOUTH SUPPORT WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:781-891-0556
Mailing Address - Street 1:118 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5465
Mailing Address - Country:US
Mailing Address - Phone:781-891-0556
Mailing Address - Fax:
Practice Address - Street 1:118 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5465
Practice Address - Country:US
Practice Address - Phone:781-891-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health