Healthcare Provider Details

I. General information

NPI: 1851517304
Provider Name (Legal Business Name): LOURDESMONT BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 WYOMING AVE
SCRANTON PA
18509-2861
US

IV. Provider business mailing address

1327 WYOMING AVE
SCRANTON PA
18509-2861
US

V. Phone/Fax

Practice location:
  • Phone: 570-702-8360
  • Fax: 570-702-8623
Mailing address:
  • Phone: 570-702-8360
  • Fax: 570-702-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number1420220
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007283070006
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. SAL SANTOLI
Title or Position: COO
Credential: M.S.
Phone: 570-348-6100