Provider Demographics
NPI:1619226214
Name:FAMILY PRESERVATION SERVICES, INC
Entity Type:Organization
Organization Name:FAMILY PRESERVATION SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:FIDGEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-710-6085
Mailing Address - Street 1:10304 SPOTSYLVANIA AVENUE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:FREDERICKSBUEG
Mailing Address - State:VA
Mailing Address - Zip Code:22408
Mailing Address - Country:US
Mailing Address - Phone:540-710-6085
Mailing Address - Fax:540-710-6447
Practice Address - Street 1:5267 OLD NOTTOWAY ROAD
Practice Address - Street 2:
Practice Address - City:CREWE
Practice Address - State:VA
Practice Address - Zip Code:23936
Practice Address - Country:US
Practice Address - Phone:434-392-3328
Practice Address - Fax:434-392-3235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA158 02 029251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA158 02 029Medicaid