Provider Demographics
NPI:1912070731
Name:SYVERSON, NINA JEAN (MA, MSE,LP)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:JEAN
Last Name:SYVERSON
Suffix:
Gender:F
Credentials:MA, MSE,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 81ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2111
Mailing Address - Country:US
Mailing Address - Phone:763-780-3036
Mailing Address - Fax:763-784-0784
Practice Address - Street 1:14165 JAMES RD STE 200
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9317
Practice Address - Country:US
Practice Address - Phone:763-428-6330
Practice Address - Fax:763-428-6314
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1892103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical