Provider Demographics
NPI:1669690467
Name:WAYSIDE YOUTH & FAMILY SUPPORT NETWORK
Entity type:Organization
Organization Name:WAYSIDE YOUTH & FAMILY SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:MASI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-879-9800
Mailing Address - Street 1:75 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6210
Mailing Address - Country:US
Mailing Address - Phone:508-879-9800
Mailing Address - Fax:508-875-1348
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:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0592251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6119935OtherHARVARD PILGRIM
MA8710897OtherCIGNA
MAEI0019OtherBLUE CROSS BLE SHIELD
MA1803689Medicaid