Healthcare Provider Details

I. General information

NPI: 1508137167
Provider Name (Legal Business Name): AARON NYSTEDT B.C.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 MONTEREY BLVD SUITE A
SAN FRANCISCO CA
94131
US

IV. Provider business mailing address

2700 1ST ST N SUITE 103
SAINT CLOUD MN
56303-4256
US

V. Phone/Fax

Practice location:
  • Phone: 877-264-6747
  • Fax:
Mailing address:
  • Phone: 320-259-6022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8098
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: