Provider Demographics
NPI:1700983368
Name:NYSTROM, BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 N WACO AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3972
Mailing Address - Country:US
Mailing Address - Phone:316-616-0260
Mailing Address - Fax:316-616-0264
Practice Address - Street 1:4013 N RIDGE RD STE 110
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-8859
Practice Address - Country:US
Practice Address - Phone:316-616-0260
Practice Address - Fax:316-616-0264
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS610103T00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC2200X, 103TF0000X, 103TF0200X, 103TH0100X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100239970 BMedicaid
KSR31094Medicare UPIN