Healthcare Provider Details

I. General information

NPI: 1689720302
Provider Name (Legal Business Name): WESTSIDE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 CHRISTY DRIVE SUITE 3
BROCKTON MA
02301
US

IV. Provider business mailing address

7 CHRISTY DRIVE SUITE 3
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 508-580-4611
  • Fax: 508-580-4404
Mailing address:
  • Phone: 508-580-4611
  • Fax: 508-580-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7330
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number8177
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104590
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110746
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1027200
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number94523
License Number StateMA
# 7
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number90943
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35081
License Number StateMA
# 9
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number135140
License Number StateMA
# 10
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105028
License Number StateMA

VIII. Authorized Official

Name: MICHAEL STEPHEN WEINER
Title or Position: PARTENER
Credential: LICSW
Phone: 508-580-4611