Basic Information
| Provider Information | |||||||||
| NPI: | 1497181663 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224088602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407106085 | ||||||||
| FaxNumber: | 5407106447 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 BLUE GRAY ROAD | ||||||||
| Address2: | |||||||||
| City: | EWING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764317214 | ||||||||
| FaxNumber: | 2764317215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | SAMPSON | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
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| AuthorizedOfficialTitleorPosition: | VIRGINIA STATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5407106085 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 |