Provider Demographics
NPI:1558796565
Name:NYSTROM, LAURA LOPEZ (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LOPEZ
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 ROBIE ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2415
Mailing Address - Country:US
Mailing Address - Phone:651-222-0757
Mailing Address - Fax:651-290-2703
Practice Address - Street 1:381 ROBIE ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2415
Practice Address - Country:US
Practice Address - Phone:651-222-0757
Practice Address - Fax:651-290-2703
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical