Provider Demographics
NPI:1396045225
Name:NYSTROM, KARIN M (LICSW)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:M
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:M
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5205
Practice Address - Street 1:2649 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1006
Practice Address - Country:US
Practice Address - Phone:612-676-1604
Practice Address - Fax:612-379-8235
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN205031041C0700X
CO8161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical