Basic Information
| Provider Information | |||||||||
| NPI: | 1285822833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYSTROM | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW, LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
| FaxNumber: | 2539683278 | ||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| Address2: | 9040 REID ST., ATTN: MCHJ-QCR | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
| FaxNumber: | 2539683278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00006484 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.