Basic Information
Provider Information | |||||||||
NPI: | 1831290543 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NYSTROMBALFE | ||||||||
FirstName: | BRITT | ||||||||
MiddleName: | ERIKA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NYSTROM | ||||||||
OtherFirstName: | BRITT | ||||||||
OtherMiddleName: | ERIKA | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LICSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 4933 SHERIDAN AVE S | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554101920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6129200749 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3450 OLEARY LN | ||||||||
Address2: |   | ||||||||
City: | EAGAN | ||||||||
State: | MN | ||||||||
PostalCode: | 551232340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514540114 | ||||||||
FaxNumber: | 6514543492 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16590 | MN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 41-1576550 | 01 |   | PRACTICE FED TAX ID# | OTHER |