Basic Information
| Provider Information | |||||||||
| NPI: | 1871873422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, LLC FLAT ROCK MIDDLE | ||||||||
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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: | 191 PRESTON LN | ||||||||
| Address2: | |||||||||
| City: | EAST FLAT ROCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287262865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043440491 | ||||||||
| FaxNumber: | 7043440493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2011 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | FREELEY | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | NC BILLING SYSTEM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8302950R | 05 | NC | MEDICAID | 8303416R | 05 | NC | MEDICAID |