Provider Demographics
NPI:1275526212
Name:NEWSOM, WALTER SCOTT (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:SCOTT
Last Name:NEWSOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:SCOTT
Other - Last Name:NEWSOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH,D
Mailing Address - Street 1:2101 LANIER DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7736
Mailing Address - Country:US
Mailing Address - Phone:855-640-1700
Mailing Address - Fax:855-640-1700
Practice Address - Street 1:8500 SHOAL CREEK BLVD
Practice Address - Street 2:BUILDING 4, SUITE 201A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7591
Practice Address - Country:US
Practice Address - Phone:855-640-1700
Practice Address - Fax:855-640-1700
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31249103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145043901Medicaid