Basic Information
| Provider Information | |||||||||
| NPI: | 1790872562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYSTROM & ASSOCIATES LTD. / PROFESSIONAL FAMILY BASED DIV. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROFESSIONAL FAMILY BASED DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD. NW | ||||||||
| Address2: | #110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD. NW | ||||||||
| Address2: | #110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289253 | ||||||||
| FaxNumber: | 6516318789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | NYSTROM | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6516289566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT, LICSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 77519900 | 05 | MN | MEDICAID |