{
"Npi": {
"NPI": "1174738520",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LAKE NORMAN INTEGRATIVE PSYCHIATRY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "116 S MAIN ST STE 301",
"SecondLineMailingAddress": "P.O. BOX 1247",
"MailingAddressCityName": "MOORESVILLE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28115-2373",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "704-662-3200",
"MailingAddressFaxNumber": "704-662-8731",
"FirstLinePracticeLocationAddress": "116 S MAIN ST STE 301",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MOORESVILLE",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "28115-2373",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "704-662-3200",
"PracticeLocationAddressFaxNumber": "704-662-1247",
"EnumerationDate": "05/11/2007",
"LastUpdateDate": "10/03/2007",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LATZ",
"AuthorizedOfficialFirstName": "TRACY",
"AuthorizedOfficialMiddleName": "THOMPSON",
"AuthorizedOfficialTitle": "SOLE OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D., M.S.",
"AuthorizedOfficialTelephoneNumber": "704-662-3200",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM2500X",
"TaxonomyName": "Medical Specialty Clinic/Center",
"LicenseNumber": "34660",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}