Provider Demographics
NPI:1225585169
Name:NYSTROM, HEATHER (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 N MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-2934
Mailing Address - Country:US
Mailing Address - Phone:313-207-1651
Mailing Address - Fax:
Practice Address - Street 1:3411 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-2934
Practice Address - Country:US
Practice Address - Phone:313-207-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010920951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical