Basic Information
| Provider Information | |||||||||
| NPI: | 1164871604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ELLENBORO ELEMENTARY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759194 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212759195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043440491 | ||||||||
| FaxNumber: | 7043440493 | ||||||||
| Practice Location | |||||||||
| Address1: | 813 PINEY MOUNTAIN CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | ELLENBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280408656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043440491 | ||||||||
| FaxNumber: | 7043440493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREELEY | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | NC BILLING SYSTEMS SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.