Provider Demographics
NPI:1467761742
Name:NYSTROM & ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:NYSTROM & ASSOCIATES, LTD.
Other - Org Name:NYSTROM & ASSOCIATES, LTD. ADULT DAY TREATMENT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NYSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:651-379-1734
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health