Provider Demographics
NPI:1164693529
Name:NYSTROM, BETH ERICA (PT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ERICA
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3187
Mailing Address - Country:US
Mailing Address - Phone:815-334-8850
Mailing Address - Fax:815-334-8853
Practice Address - Street 1:665 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3187
Practice Address - Country:US
Practice Address - Phone:815-334-8850
Practice Address - Fax:815-334-8853
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05627401OtherBLUE CROSS BLUE SHIELD
ILK52042Medicare PIN