MEDICARE: MR. SHAWN KEITH HARTZOG LPA

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	101YM0800X	Mental Health Counselor	2262	NC
2	103T00000X	Psychologist	2262	NC
3	103TC2200X	Clinical Child & Adolescent Psychologist	2262	NC
4	103TF0000X	Family Psychologist	2262	NC
5	103TH0100X	Health Service Psychologist	2262	NC
6	103TP2701X	Group Psychotherapy Psychologist	2262	NC
7	103TF0200X	Forensic Psychologist	2262	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629104641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHAWN KEITH HARTZOG LPA

Provider Business Mailing Address
First Line	:	154 MEDICAL PARK LOOP
Second Line	:
City	:	SYLVA
State	:	NC
Zip	:	28779-5271
Country	:	US
Telephone Number	:	828-319-1080
Fax Number	:	828-631-9280

Provider Business Practice Location Address
First Line	:	154 MEDICAL PARK LOOP
Second Line	:
City	:	SYLVA
State	:	NC
Zip	:	28779-5271
Country	:	US
Telephone Number	:	828-319-1080
Fax Number	:	828-631-9280

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	04/19/2010

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Directions to “ MR. SHAWN KEITH HARTZOG LPA” Practice Location

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