Provider Demographics
NPI:1831290543
Name:NYSTROMBALFE, BRITT ERIKA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:BRITT
Middle Name:ERIKA
Last Name:NYSTROMBALFE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:BRITT
Other - Middle Name:ERIKA
Other - Last Name:NYSTROM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:4933 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1920
Mailing Address - Country:US
Mailing Address - Phone:612-920-0749
Mailing Address - Fax:
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN165901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
41-1576550OtherPRACTICE FED TAX ID#