Healthcare Provider Details

I. General information

NPI: 1780711309
Provider Name (Legal Business Name): LDS FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W JACKSON RD
CARROLLTON TX
75006-1316
US

IV. Provider business mailing address

1100 W JACKSON RD
CARROLLTON TX
75006-1316
US

V. Phone/Fax

Practice location:
  • Phone: 972-242-2182
  • Fax: 972-242-2932
Mailing address:
  • Phone: 972-242-2182
  • Fax: 972-242-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number497
License Number StateTX

VIII. Authorized Official

Name: ERIC FERNELIUS
Title or Position: DIRECTOR
Credential: LCSW
Phone: 972-242-2182