Provider Demographics
NPI:1629104641
Name:HARTZOG, SHAWN KEITH (LPA)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:KEITH
Last Name:HARTZOG
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 MEDICAL PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-5271
Mailing Address - Country:US
Mailing Address - Phone:828-319-1080
Mailing Address - Fax:828-631-9280
Practice Address - Street 1:154 MEDICAL PARK LOOP
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5271
Practice Address - Country:US
Practice Address - Phone:828-319-1080
Practice Address - Fax:828-631-9280
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2262101YM0800X, 103T00000X, 103TC2200X, 103TF0000X, 103TH0100X, 103TP2701X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107428Medicaid