Provider Demographics
NPI:1699355339
Name:NYSTROM, KATIE MICHELLE (LICSW, MSW)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LICSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21668104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker