Provider Demographics
NPI:1568674752
Name:LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC
Entity Type:Organization
Organization Name:LAKE NORMAN PSYCHIATRY & COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LATZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-662-3200
Mailing Address - Street 1:116 SOUTH MAIN STREET SUITE 205
Mailing Address - Street 2:PO BOX 900
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-0900
Mailing Address - Country:US
Mailing Address - Phone:704-662-3270
Mailing Address - Fax:704-662-3288
Practice Address - Street 1:116 SOUTH MAIN STREET SUITE 205
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-0900
Practice Address - Country:US
Practice Address - Phone:704-662-3270
Practice Address - Fax:704-662-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC356882084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0276ROtherBCBS GROUP NUMBER
NC890276RMedicaid
NC2326601Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER