Provider Demographics
NPI:1649701277
Name:FAMILY ALTERNATIVE SUPPORT SERVICES
Entity type:Organization
Organization Name:FAMILY ALTERNATIVE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENYETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-575-2708
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:NEWELL
Mailing Address - State:NC
Mailing Address - Zip Code:28126-0028
Mailing Address - Country:US
Mailing Address - Phone:704-575-2708
Mailing Address - Fax:
Practice Address - Street 1:3205 MALLARD HILL DR
Practice Address - Street 2:107
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-2023
Practice Address - Country:US
Practice Address - Phone:704-575-2708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health