MEDICARE: JAN LARAE EVERHART NEWMAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	5013	NC
2	103TC2200X	Clinical Child & Adolescent Psychologist	5013	NC
3	103TC0700X	Clinical Psychologist	5013	NC

General Provider Information

NPI Number	:	1336515873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN LARAE EVERHART NEWMAN PH.D.

Provider Business Mailing Address
First Line	:	301 S MCDOWELL ST STE 125
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-0031
Country	:	US
Telephone Number	:	704-444-0087
Fax Number	:

Provider Business Practice Location Address
First Line	:	3318 PARTING BROOK CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-8159
Country	:	US
Telephone Number	:	704-444-0087
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2015
Last Update Date	:	08/23/2022

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