Basic Information
Provider Information | |||||||||
NPI: | 1174759831 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY PRESERVATION SERVICES OF NC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 759194 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212759194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407106085 | ||||||||
FaxNumber: | 5407106447 | ||||||||
Practice Location | |||||||||
Address1: | 53 S FRENCH BROAD AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288013272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282253100 | ||||||||
FaxNumber: | 8282253604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2009 | ||||||||
LastUpdateDate: | 07/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LITTLE | ||||||||
AuthorizedOfficialFirstName: | MIRANDA | ||||||||
AuthorizedOfficialMiddleName: | KAYE | ||||||||
AuthorizedOfficialTitleorPosition: | NC QI & TRAINING DIR | ||||||||
AuthorizedOfficialTelephone: | 7043440491 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP0808X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 5906873 | 05 | NC |   | MEDICAID |