Basic Information
| Provider Information | |||||||||
| NPI: | 1326127226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759194 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212759194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282253100 | ||||||||
| FaxNumber: | 8282253604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 PATTON AVE STE D | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288062652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282253100 | ||||||||
| FaxNumber: | 8282253604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | NC STATE QI & TRAINING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8301588 | 05 | NC | MEDICAID |