Provider Demographics
NPI:1669507224
Name:FAMILY PRESERVATION SERVICES OF NORTH CAROLINA LLC
Entity Type:Organization
Organization Name:FAMILY PRESERVATION SERVICES OF NORTH CAROLINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NC BILLING SYSTEM SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-344-0491
Mailing Address - Street 1:PO BOX 759194
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9194
Mailing Address - Country:US
Mailing Address - Phone:704-344-0491
Mailing Address - Fax:704-344-0493
Practice Address - Street 1:2300 SARDIS RD N STE M
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7712
Practice Address - Country:US
Practice Address - Phone:704-344-0491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X, 106H00000X, 251S00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 104100000X, 1041C0700X, 106H00000X, 251S00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005523Medicaid