Provider Demographics
NPI:1225287105
Name:NYSTROM, NANCY M (PHD, MSW,LICSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:M
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:PHD, MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 REST PL NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9632
Mailing Address - Country:US
Mailing Address - Phone:360-405-0111
Mailing Address - Fax:
Practice Address - Street 1:5310 REST PL NE
Practice Address - Street 2:SUITE A
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-9632
Practice Address - Country:US
Practice Address - Phone:360-405-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60015378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8877194Medicare PIN