Provider Demographics
NPI:1912961681
Name:NEWSOM, MICHELLE (MPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WILLOW LAWN DR
Mailing Address - Street 2:STE 230
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3003
Mailing Address - Country:US
Mailing Address - Phone:804-340-1193
Mailing Address - Fax:804-340-1930
Practice Address - Street 1:3805 CUTSHAW AVE
Practice Address - Street 2:SUITE 299
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:804-340-1193
Practice Address - Fax:801-340-1930
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
54960OtherMEDICAID HMO
184946OtherANTHEM PPO
184946OtherHEALTHKEEPERS
429180OtherMAMSI
183574OtherANTHEM PPO
329180OtherMAMSI
412143526OtherPHCS
7630753OtherAETNA HMO
255534OtherSOUTHERN HEALTH
6400713OtherUNITED HEALTHCARE
7630753OtherAETNA
6404543OtherUNITED HEALTHCARE
143281OtherAN/HK
412143526OtherCIGNA
255534OtherSOUTHERN HEALTH
009173R75Medicare ID - Type Unspecified