Provider Demographics
NPI:1710323597
Name:NORDSTROM, JOSHUA (LSW)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 ANTLER CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-9219
Mailing Address - Country:US
Mailing Address - Phone:847-275-5674
Mailing Address - Fax:
Practice Address - Street 1:2458 ANTLER CT
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-9219
Practice Address - Country:US
Practice Address - Phone:847-275-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.12007471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical