Provider Demographics
NPI:1235565722
Name:NYSTROM, TARA MARIE (MS, MHC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MS, MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1102
Mailing Address - Country:US
Mailing Address - Phone:631-648-8312
Mailing Address - Fax:
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-920-8302
Practice Address - Fax:631-920-8462
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health