Basic Information
| Provider Information | |||||||||
| NPI: | 1629104641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTZOG | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 MEDICAL PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287795271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283191080 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Practice Location | |||||||||
| Address1: | 154 MEDICAL PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287795271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283191080 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2262 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | 2262 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC2200X | 2262 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0000X | 2262 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Family | 103TH0100X | 2262 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TP2701X | 2262 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TF0200X | 2262 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Forensic |
ID Information
| ID | Type | State | Issuer | Description | 6107428 | 05 | NC | MEDICAID |