MEDICARE: ELIZABETH NEWTON PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY003626	GA

General Provider Information

NPI Number	:	1801137690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH NEWTON PSYD

Provider Business Mailing Address
First Line	:	4255 WADE GREEN RD NW
Second Line	:	STE 414
City	:	KENNESAW
State	:	GA
Zip	:	30144-1762
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4255 WADE GREEN RD NW
Second Line	:	STE 414
City	:	KENNESAW
State	:	GA
Zip	:	30144-1762
Country	:	US
Telephone Number	:	678-213-2194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2013
Last Update Date	:	03/05/2013

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