=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699910133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRESERVATION SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2008
-----------------------------------------------------
Last Update Date | 12/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 RIVERSIDE DR
-----------------------------------------------------
City | BASSETT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24055-4246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-632-1113
-----------------------------------------------------
Fax | 276-632-0923
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10304 SPOTSYLVANIA AVE 3RD FLOOR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22408-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-710-6085
-----------------------------------------------------
Fax | 540-710-6447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL C FIDGEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-710-6085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 158 02 029
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------