Provider Demographics
NPI:1174738520
Name:LAKE NORMAN INTEGRATIVE PSYCHIATRY
Entity type:Organization
Organization Name:LAKE NORMAN INTEGRATIVE PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:THOMPSON
Authorized Official - Last Name:LATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:704-662-3200
Mailing Address - Street 1:116 S MAIN ST STE 301
Mailing Address - Street 2:P.O. BOX 1247
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2373
Mailing Address - Country:US
Mailing Address - Phone:704-662-3200
Mailing Address - Fax:704-662-8731
Practice Address - Street 1:116 S MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2373
Practice Address - Country:US
Practice Address - Phone:704-662-3200
Practice Address - Fax:704-662-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34660261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7951148Medicaid
NC1407879851OtherDR LATZ NPI NUMBER
NC2168522C NCMedicare ID - Type UnspecifiedDR LATZ MCARE NUMBER
NC7951148Medicaid