Healthcare Provider Details

I. General information

NPI: 1396750188
Provider Name (Legal Business Name): NYSTROM & ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 651-628-9566
  • Fax: 651-628-0411
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06197
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0145
License Number StateMN

VIII. Authorized Official

Name: ANN EIDEN
Title or Position: VP OF OPERATIONS
Credential:
Phone: 651-379-1750