Basic Information
| Provider Information | |||||||||
| NPI: | 1043445471 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224088602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282876110 | ||||||||
| FaxNumber: | 8282876092 | ||||||||
| Practice Location | |||||||||
| Address1: | 356 CHARLOTTE RD | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281392916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282877945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | FREELEY | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | NC BILLING SYSTEM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8301589V | 05 | NC | MEDICAID | 8301589B | 05 | NC | MEDICAID |