Provider Demographics
NPI:1982724027
Name:NYSTROM, DEBRA (MFT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20258 US HIGHWAY 18 STE 430-449
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-6197
Mailing Address - Country:US
Mailing Address - Phone:760-946-2804
Mailing Address - Fax:
Practice Address - Street 1:20601 US HIGHWAY 18 STE 158
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-3567
Practice Address - Country:US
Practice Address - Phone:760-946-2804
Practice Address - Fax:760-946-0378
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health