Provider Demographics
NPI:1376128033
Name:NYSTROM, OLIVIA HAYLEY
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:HAYLEY
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2265
Mailing Address - Country:US
Mailing Address - Phone:815-382-5877
Mailing Address - Fax:
Practice Address - Street 1:708 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2265
Practice Address - Country:US
Practice Address - Phone:815-382-8770
Practice Address - Fax:815-338-1786
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker