Basic Information
Provider Information | |||||||||
NPI: | 1174776959 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY PREERVATION SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224088602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407106085 | ||||||||
FaxNumber: | 5407106447 | ||||||||
Practice Location | |||||||||
Address1: | 800 EUSTACE RD | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | VA | ||||||||
PostalCode: | 225543794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403721438 | ||||||||
FaxNumber: | 5403727071 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2008 | ||||||||
LastUpdateDate: | 10/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FIDGEON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5407103085 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 158 02 029 | VA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 158 02 029 | 05 | VA |   | MEDICAID |