Provider Demographics
NPI:1790872562
Name:NYSTROM & ASSOCIATES LTD. / PROFESSIONAL FAMILY BASED DIV.
Entity Type:Organization
Organization Name:NYSTROM & ASSOCIATES LTD. / PROFESSIONAL FAMILY BASED DIV.
Other - Org Name:PROFESSIONAL FAMILY BASED DIVISION
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:NYSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LICSW
Authorized Official - Phone:651-628-9566
Mailing Address - Street 1:1900 SILVER LAKE RD. NW
Mailing Address - Street 2:#110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1900 SILVER LAKE RD. NW
Practice Address - Street 2:#110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:651-628-9253
Practice Address - Fax:651-631-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN77519900Medicaid