1720130453 NPI number — WAYSIDE YOUTH AND FAMILY SUPPORT NETWORK

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720130453 NPI number — WAYSIDE YOUTH AND FAMILY SUPPORT NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYSIDE YOUTH AND FAMILY SUPPORT NETWORK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720130453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 COMMONWEALTH AVE.
Provider Second Line Business Mailing Address:
UNIT 3
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-515-7309
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02148-5119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-338-2640
Provider Business Practice Location Address Fax Number:
781-338-2217
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
ALI
Authorized Official Middle Name:
SARAH
Authorized Official Title or Position:
HOMEBASE CLINICIAN
Authorized Official Telephone Number:
781-338-2640

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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