Provider Demographics
NPI:1093573222
Name:NYSTROM, BROOKE (OTR/L, MOT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:OTR/L, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LAKE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1333
Mailing Address - Country:US
Mailing Address - Phone:415-298-3396
Mailing Address - Fax:
Practice Address - Street 1:1100 VAN NESS AVE FL 6
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12449225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist