Basic Information
| Provider Information | |||||||||
| NPI: | 1174689079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NYSTROM | ||||||||
| FirstName: | WALTER | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106158880 | ||||||||
| FaxNumber: | 2106152279 | ||||||||
| Practice Location | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106158880 | ||||||||
| FaxNumber: | 2106152279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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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 | 101YP2500X | 14898 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.