Healthcare Provider Details

I. General information

NPI: 1982939823
Provider Name (Legal Business Name): EASTOVER PSYCHOLOGICAL & PSYCHIATRIC GROUP OF LAKE NORMAN, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20723 TORRENCE CHAPEL RD SUITE 203
CORNELIUS NC
28031-6496
US

IV. Provider business mailing address

20723 TORRENCE CHAPEL RD SUITE 203
CORNELIUS NC
28031-6496
US

V. Phone/Fax

Practice location:
  • Phone: 704-987-2560
  • Fax: 704-987-2561
Mailing address:
  • Phone: 704-987-2560
  • Fax: 704-987-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number144566
License Number StateNC

VIII. Authorized Official

Name: DR. JOHN EDWARD HUMPHREY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-362-2663