Basic Information
| Provider Information | |||||||||
| NPI: | 1619226214 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10304 SPOTSYLVANIA AVENUE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | FREDERICKSBUEG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407106085 | ||||||||
| FaxNumber: | 5407106447 | ||||||||
| Practice Location | |||||||||
| Address1: | 5267 OLD NOTTOWAY ROAD | ||||||||
| Address2: | |||||||||
| City: | CREWE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343923328 | ||||||||
| FaxNumber: | 4343923235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | FIDGEON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5407106085 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |