Provider Demographics
NPI:1821285461
Name:NYSTROM, HANNAH WEDGLEY (PHD)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:WEDGLEY
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 MARKET ST
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-3002
Mailing Address - Country:US
Mailing Address - Phone:415-474-5820
Mailing Address - Fax:415-520-9239
Practice Address - Street 1:870 MARKET ST
Practice Address - Street 2:SUITE 1101
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3002
Practice Address - Country:US
Practice Address - Phone:415-474-5820
Practice Address - Fax:415-520-9239
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical