Basic Information
Provider Information | |||||||||
NPI: | 1215138565 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY PRESERVATION 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: | 250 STATESMAN DRIVE | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE COURT HOUSE | ||||||||
State: | VA | ||||||||
PostalCode: | 23923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4346964633 | ||||||||
FaxNumber: | 4346964634 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FIDGEON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 5407106085 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 15802029 | VA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 15802029 | 05 | VA |   | MEDICAID |