Healthcare Provider Details

I. General information

NPI: 1649408402
Provider Name (Legal Business Name): FAMILY PRESERVATION SERVICES OF NC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CAROLINA DR
TRYON NC
28782-0015
US

IV. Provider business mailing address

PO BOX 759194
BALTIMORE MD
21275-9194
US

V. Phone/Fax

Practice location:
  • Phone: 828-859-6661
  • Fax: 828-859-9487
Mailing address:
  • Phone: 540-710-6085
  • Fax: 540-710-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5906871
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MIRANDA KAYE LITTLE
Title or Position: NC & QI & TRAINING DIR
Credential:
Phone: 704-344-0491