Basic Information
| Provider Information | |||||||||
| NPI: | 1790938801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759194 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212759194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7105406085 | ||||||||
| FaxNumber: | 7105406447 | ||||||||
| Practice Location | |||||||||
| Address1: | 3824 BARRETT DR | ||||||||
| Address2: | SUITE200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043440491 | ||||||||
| FaxNumber: | 7042330493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | NC QI & TRAINING DIR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE SERVICE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC1900X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103TS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | School | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8302457 | 05 | NC | MEDICAID |