Healthcare Provider Details

I. General information

NPI: 1619703683
Provider Name (Legal Business Name): STEPHANI NEWSOME EDS, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANI NEWSOME MED, EDS, NCSP

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5865 E 50 S
LAFAYETTE IN
47905-8731
US

IV. Provider business mailing address

5865 E 50 S
LAFAYETTE IN
47905-8731
US

V. Phone/Fax

Practice location:
  • Phone: 765-772-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10188192
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: