Basic Information
Provider Information | |||||||||
NPI: | 1407999865 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY PRESERVATION SERVICES OF WEST VIRGINIA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224088602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407106085 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 285 W BIRCH LN | ||||||||
Address2: |   | ||||||||
City: | ROMNEY | ||||||||
State: | WV | ||||||||
PostalCode: | 267571610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3048222670 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 06/27/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELTON SEE | ||||||||
AuthorizedOfficialFirstName: | LESLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | STATE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3048222670 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 147 | WV | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.