Provider Demographics
NPI:1891113361
Name:NYSTROM, KRISTINE ELIN (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELIN
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1444
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-1444
Mailing Address - Country:US
Mailing Address - Phone:503-382-9654
Mailing Address - Fax:
Practice Address - Street 1:1106 HARRIS AVE STE 210
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7001
Practice Address - Country:US
Practice Address - Phone:503-382-9654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3385101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500676787Medicaid