Provider Demographics
NPI:1174689079
Name:NYSTROM, WALTER (LPC)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7272 WURZBACH RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4801
Mailing Address - Country:US
Mailing Address - Phone:210-615-8880
Mailing Address - Fax:210-615-2279
Practice Address - Street 1:7272 WURZBACH RD
Practice Address - Street 2:SUITE 601
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4801
Practice Address - Country:US
Practice Address - Phone:210-615-8880
Practice Address - Fax:210-615-2279
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14898101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional