Provider Demographics
| NPI: | 1790938801 |
|---|---|
| Name: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, INC |
| Entity Type: | Organization |
| Organization Name: | FAMILY PRESERVATION SERVICES OF NORTH CAROLINA, INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | NC QI & TRAINING DIR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | MIRANDA |
| Authorized Official - Middle Name: | KAYE |
| Authorized Official - Last Name: | LITTLE |
| 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: | 710-540-6085 |
| Mailing Address - Fax: | 710-540-6447 |
| Practice Address - Street 1: | 3824 BARRETT DR |
| Practice Address - Street 2: | SUITE200 |
| Practice Address - City: | RALEIGH |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 27609-7220 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-344-0491 |
| Practice Address - Fax: | 704-233-0493 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PROVIDENCE SERVICE CORPORATION |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2008-11-03 |
| Last Update Date: | 2014-09-11 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 103TS0200X | Behavioral Health & Social Service Providers | Psychologist | School | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | 8302457 | Medicaid |
