Provider Demographics
NPI:1154942258
Name:NYSTROM, NAOMI (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSYCHOLOGY - BUILDING A
Mailing Address - Street 2:3301 7TH AVE. N.
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:651-242-8330
Mailing Address - Fax:
Practice Address - Street 1:PSYCHOLOGY - BUILDING A
Practice Address - Street 2:3301 7TH AVE. N.
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:651-242-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6316103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty