=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568674752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 SOUTH MAIN STREET SUITE 205
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28115-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-662-3270
-----------------------------------------------------
Fax | 704-662-3288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 SOUTH MAIN STREET SUITE 205 PO BOX 900
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28115-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-662-3270
-----------------------------------------------------
Fax | 704-662-3288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | DR. JOHN EDWARD LATZ JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-662-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0015X
-----------------------------------------------------
Taxonomy Name | Psychosomatic Medicine Physician
-----------------------------------------------------
License Number | 35688
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------