Provider Demographics
NPI:1780711309
Name:LDS FAMILY SERVICES
Entity type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:972-242-2182
Mailing Address - Street 1:1100 W JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-1316
Mailing Address - Country:US
Mailing Address - Phone:972-242-2182
Mailing Address - Fax:972-242-2932
Practice Address - Street 1:1100 W JACKSON RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1316
Practice Address - Country:US
Practice Address - Phone:972-242-2182
Practice Address - Fax:972-242-2932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-28
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX497261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0003NFOtherBLUE CROSS BLUE SHIELD