Provider Demographics
NPI:1033667100
Name:NYSTROM, KASSANDRA LYNNE (MA)
Entity Type:Individual
Prefix:MS
First Name:KASSANDRA
Middle Name:LYNNE
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:KASSANDRA
Other - Middle Name:LYNNE
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:4409 MURFREESBORO HWY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3249
Mailing Address - Country:US
Mailing Address - Phone:615-448-7222
Mailing Address - Fax:
Practice Address - Street 1:4409 MURFREESBORO HWY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3249
Practice Address - Country:US
Practice Address - Phone:615-448-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health