Basic Information
| Provider Information | |||||||||
| NPI: | 1124445762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CENTERED SERVICES OF ALASKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARIKA RD | ||||||||
| Address2: | FAIRBANKS | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074740890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1825 MARIKA RD | ||||||||
| Address2: | FAIRBANKS | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074740890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2014 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | LARA | ||||||||
| AuthorizedOfficialFirstName: | ANGELIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | YOUTH COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 9157315160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 10Y00000X | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | MH3237 | 05 | AK | MEDICAID |