Provider Demographics
NPI:1922186352
Name:BETHESDA CHILDRENS HOME/LSS
Entity Type:Organization
Organization Name:BETHESDA CHILDRENS HOME/LSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-724-7510
Mailing Address - Street 1:15487 STATE HIGHWAY 86
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-5316
Mailing Address - Country:US
Mailing Address - Phone:814-724-7510
Mailing Address - Fax:814-724-8686
Practice Address - Street 1:15487 STATE HIGHWAY 86
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-5316
Practice Address - Country:US
Practice Address - Phone:814-724-7510
Practice Address - Fax:814-724-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA458860261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100773910Medicare ID - Type Unspecified