Basic Information
| Provider Information | |||||||||
| NPI: | 1679891337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759194 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212759194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282253100 | ||||||||
| FaxNumber: | 8282253604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 W SUGAR CREEK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9803435231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 02/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | NC QI & TRAINING DIR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE SERVICE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8303135R | 05 | NC | MEDICAID |