Healthcare Provider Details

I. General information

NPI: 1639635980
Provider Name (Legal Business Name): WAYSIDE HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 NE 6TH AVE
DELRAY BEACH FL
33483-5517
US

IV. Provider business mailing address

378 NE 6TH AVE
DELRAY BEACH FL
33483
US

V. Phone/Fax

Practice location:
  • Phone: 561-666-9154
  • Fax: 561-294-0178
Mailing address:
  • Phone: 561-666-9168
  • Fax: 561-294-0178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA GAIL MCWHORTER
Title or Position: CEO
Credential:
Phone: 561-666-9154