Provider Demographics
NPI:1326075813
Name:NYSTROM, BRIAN ARTHUR (LICSW, LMFT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ARTHUR
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:LICSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRIGHTON PROFESSIONAL BLDG
Mailing Address - Street 2:1900 SILVER LAKE ROAD #110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:NE
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:BRIGHTON PROFESSIONAL BLDG
Practice Address - Street 2:1900 SILVER LAKE ROAD #110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN061971041C0700X
MN0145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001857100Medicaid
MN800000154Medicare Oscar/Certification
MN800012847Medicare PIN