Provider Demographics
NPI:1043516008
Name:THE CENTER AT LAKE NORMAN
Entity type:Organization
Organization Name:THE CENTER AT LAKE NORMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFTA
Authorized Official - Phone:704-980-9234
Mailing Address - Street 1:132 JOE KNOX AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9203
Mailing Address - Country:US
Mailing Address - Phone:704-980-9234
Mailing Address - Fax:866-321-9367
Practice Address - Street 1:132 JOE KNOX AVE STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9203
Practice Address - Country:US
Practice Address - Phone:704-980-9234
Practice Address - Fax:866-321-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7015A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty