Provider Demographics
NPI:1932134350
Name:NORDSTROM, PAULA MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:MICHELLE
Last Name:NORDSTROM
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 1:90 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1057
Mailing Address - Country:US
Mailing Address - Phone:208-828-7139
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-828-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY - 303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002532600Medicaid
IDS04813Medicare UPIN
ID002532600Medicaid