Provider Demographics
NPI:1225193030
Name:GLADE RUN LUTHERAN SERVICES
Entity Type:Organization
Organization Name:GLADE RUN LUTHERAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-452-4453
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-0070
Mailing Address - Country:US
Mailing Address - Phone:724-452-4453
Mailing Address - Fax:724-452-6576
Practice Address - Street 1:BEAVER ROAD
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063-0070
Practice Address - Country:US
Practice Address - Phone:724-452-4453
Practice Address - Fax:724-452-6576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA414650322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100754254-0019Medicaid