Healthcare Provider Details

I. General information

NPI: 1568674752
Provider Name (Legal Business Name): LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SOUTH MAIN STREET SUITE 205
MOORESVILLE NC
28115-0900
US

IV. Provider business mailing address

116 SOUTH MAIN STREET SUITE 205 PO BOX 900
MOORESVILLE NC
28115-0900
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-3270
  • Fax: 704-662-3288
Mailing address:
  • Phone: 704-662-3270
  • Fax: 704-662-3288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number35688
License Number StateNC

VIII. Authorized Official

Name: DR. JOHN EDWARD LATZ JR.
Title or Position: MEMBER MANAGER
Credential: M.D.
Phone: 704-662-3200