Healthcare Provider Details

I. General information

NPI: 1154942258
Provider Name (Legal Business Name): NAOMI NYSTROM PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 09/06/2022
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSYCHOLOGY - BUILDING A 3301 7TH AVE. N.
ANOKA MN
55303
US

IV. Provider business mailing address

PSYCHOLOGY - BUILDING A 3301 7TH AVE. N.
ANOKA MN
55303
US

V. Phone/Fax

Practice location:
  • Phone: 651-242-8330
  • Fax:
Mailing address:
  • Phone: 651-242-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP6316
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6316
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: