Provider Demographics
NPI:1982939823
Name:EASTOVER PSYCHOLOGICAL & PSYCHIATRIC GROUP OF LAKE NORMAN, P.A.
Entity Type:Organization
Organization Name:EASTOVER PSYCHOLOGICAL & PSYCHIATRIC GROUP OF LAKE NORMAN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-362-2663
Mailing Address - Street 1:20723 TORRENCE CHAPEL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6496
Mailing Address - Country:US
Mailing Address - Phone:704-987-2560
Mailing Address - Fax:704-987-2561
Practice Address - Street 1:20723 TORRENCE CHAPEL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6496
Practice Address - Country:US
Practice Address - Phone:704-987-2560
Practice Address - Fax:704-987-2561
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTOVER PSYCHOLOGICAL & PSYCHIATRIC GROUP, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1445662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty