Provider Demographics
NPI:1801012349
Name:LOURDESMONT BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:LOURDESMONT BEHAVIORAL HEALTH SERVICES
Other - Org Name:LOURDESMONT GOOD SHEPHERD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:570-348-6100
Mailing Address - Street 1:1327 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2861
Mailing Address - Country:US
Mailing Address - Phone:570-702-8360
Mailing Address - Fax:570-702-8623
Practice Address - Street 1:537 VENARD RD
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1249
Practice Address - Country:US
Practice Address - Phone:570-587-4741
Practice Address - Fax:570-586-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283070009Medicaid