Provider Demographics
NPI:1184401762
Name:NYSTROM COUNSELING MO, PC
Entity type:Organization
Organization Name:NYSTROM COUNSELING MO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF CORPORATE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-379-1750
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 S WOODLAWN AVE STE 16
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-7647
Practice Address - Country:US
Practice Address - Phone:636-379-1779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)