Provider Demographics
NPI:1720130453
Name:WAYSIDE YOUTH AND FAMILY SUPPORT NETWORK
Entity Type:Organization
Organization Name:WAYSIDE YOUTH AND FAMILY SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOMEBASE CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:ALI
Authorized Official - Middle Name:SARAH
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:781-338-2640
Mailing Address - Street 1:1730 COMMONWEALTH AVE.
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02467
Mailing Address - Country:US
Mailing Address - Phone:617-515-7309
Mailing Address - Fax:
Practice Address - Street 1:22 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5119
Practice Address - Country:US
Practice Address - Phone:781-338-2640
Practice Address - Fax:781-338-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health