Provider Demographics
NPI:1508261157
Name:NYSTROM, KRISTY (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-0284
Mailing Address - Country:US
Mailing Address - Phone:320-218-7918
Mailing Address - Fax:320-200-7480
Practice Address - Street 1:1617 HIGHWAY 12 E STE 230
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5816
Practice Address - Country:US
Practice Address - Phone:218-791-8535
Practice Address - Fax:320-200-7480
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3059106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3059OtherLMFT LICENSE