Provider Demographics
NPI:1245093228
Name:NYSTROM, PAULA MARIE (MSW, LGSW)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIE
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3202
Mailing Address - Country:US
Mailing Address - Phone:651-529-4328
Mailing Address - Fax:
Practice Address - Street 1:652 BIELENBERG DR STE 104
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4416
Practice Address - Country:US
Practice Address - Phone:651-529-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29784104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker