Provider Demographics
NPI:1851517304
Name:LOURDESMONT BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:LOURDESMONT BEHAVIORAL HEALTH SERVICES
Other - Org Name:GOOD SHEPHERD YOUTH & FAMILY SERVICE OF NBPA
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 1:1327 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-2861
Practice Address - Country:US
Practice Address - Phone:570-702-8360
Practice Address - Fax:570-702-8623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1420220251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283070006Medicaid