Provider Demographics
NPI:1104509157
Name:NYSTROM, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:DORSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5024
Mailing Address - Country:US
Mailing Address - Phone:301-331-8704
Mailing Address - Fax:
Practice Address - Street 1:5300 WESTVIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8303
Practice Address - Country:US
Practice Address - Phone:240-242-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician