Basic Information
| Provider Information | |||||||||
| NPI: | 1528115011 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SERVICE ASSOCIATION OF SAN ANTONIO, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SAN PEDRO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102992400 | ||||||||
| FaxNumber: | 2102994498 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 SAN PEDRO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102992400 | ||||||||
| FaxNumber: | 2102994498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | GARR | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 2102992400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3600-3601 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 09631 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 17831 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 084946503 | 05 | TX | MEDICAID | 084946504 | 05 | TX | MEDICAID | 084946505 | 05 | TX | MEDICAID |