| Doctor Name: | MRS. TARA MARIE NYSTROM |
| NPI Number: | 1235565722 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MS, MHC |
| License Number: | |
| Business Practice Address: | 3600 Route 112 Coram, NY - 117274116 |
| Business Phone Number: | 6319208302 |
| Business Fax Number: | 6319208462 |
| Mailing Address: | 3 N 2nd St, HOLBROOK |
| State: | NY |
| Postal Code: | 117411102 |
| Phone Number: | 6316488312 |
| Fax Number: | |
| NPI Enumeration Date: | 09/17/2013 |
| NPI Last Update Date: | 09/17/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |