Provider Demographics
NPI:1346769122
Name:NYSTROM, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:MCCABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, OTC
Mailing Address - Street 1:347 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1619
Mailing Address - Country:US
Mailing Address - Phone:708-638-6504
Mailing Address - Fax:
Practice Address - Street 1:951 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8439
Practice Address - Country:US
Practice Address - Phone:708-638-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0046872255A2300X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program