Provider Demographics
NPI:1992210892
Name:WAYSIDE MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:WAYSIDE MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:215-789-8100
Mailing Address - Street 1:3355 LENOX RD NE STE 750
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1353
Mailing Address - Country:US
Mailing Address - Phone:215-789-8100
Mailing Address - Fax:
Practice Address - Street 1:3355 LENOX RD NE STE 750
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1353
Practice Address - Country:US
Practice Address - Phone:215-789-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health