Provider Demographics
NPI:1124592365
Name:NYSTROM, CRYSTAL ANN (LCPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-9668
Mailing Address - Country:US
Mailing Address - Phone:208-791-0129
Mailing Address - Fax:208-743-1170
Practice Address - Street 1:2335 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3242
Practice Address - Country:US
Practice Address - Phone:208-791-0129
Practice Address - Fax:208-743-1170
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60098856101YM0800X
ID5700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0675366780OtherHPSO LIABILITY INSURANCE