Provider Demographics
NPI:1093039182
Name:FAMILY SERVICE FOUNDATION, INC
Entity Type:Organization
Organization Name:FAMILY SERVICE FOUNDATION, INC
Other - Org Name:FAMILY SERVICE OF PRINCE GEORGES COUNTY, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-459-2121
Mailing Address - Street 1:5301 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:LANDOVER HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1703
Mailing Address - Country:US
Mailing Address - Phone:301-459-2121
Mailing Address - Fax:301-918-9757
Practice Address - Street 1:306 DELAWARE ROAD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4618
Practice Address - Country:US
Practice Address - Phone:301-378-0261
Practice Address - Fax:301-378-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4163103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD320741200Medicaid
MD320741200Medicaid
DC177772Medicare PIN