Individual
DR. BRUCE NYSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
4013 N RIDGE RD STE 110, WICHITA, KS 67205-8859
(316) 616-0260
(316) 616-0264
Mailing address
727 N WACO AVE STE 320, WICHITA, KS 67203-3972
(316) 616-0260
(316) 616-0264
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
610
KS
103TA0400X
Addiction (Substance Use Disorder) Psychologist
610
KS
103TA0700X
Adult Development & Aging Psychologist
610
KS
103TB0200X
Cognitive & Behavioral Psychologist
610
KS
103TC0700X
Clinical Psychologist
Primary
610
KS
103TC2200X
Clinical Child & Adolescent Psychologist
610
KS
103TF0000X
Family Psychologist
610
KS
103TF0200X
Forensic Psychologist
610
KS
103TH0100X
Health Service Psychologist
610
KS
103TP2701X
Group Psychotherapy Psychologist
610
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100239970 B
—
KS
Enumeration date
09/17/2006
Last updated
08/30/2022
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