1568674752 NPI number — LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC

Table of content: (NPI 1568674752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568674752 NPI number — LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568674752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 SOUTH MAIN STREET SUITE 205
Provider Second Line Business Mailing Address:
PO BOX 900
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28115-0900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-662-3270
Provider Business Mailing Address Fax Number:
704-662-3288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 SOUTH MAIN STREET SUITE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28115-0900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-662-3270
Provider Business Practice Location Address Fax Number:
704-662-3288
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LATZ
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
704-662-3200

Provider Taxonomy Codes

  • Taxonomy code: 2084P0015X , with the licence number:  35688 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0276R . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890276R , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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