Basic Information
| Provider Information | |||||||||
| NPI: | 1972641983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRESERVATION SERVICES OF NC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224088602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407106085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2609 N DUKE ST | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277043048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194011151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | NC QI & TRAINING DIR | ||||||||
| AuthorizedOfficialTelephone: | 7043440491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 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 | 103TH0004X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health | 103TS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | School | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 6005324 | 05 | NC | MEDICAID |