1316087950 NPI number — DR. DEBORA ANN KUSTRON PSY.D.

Table of content: (NPI 1861367278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316087950 NPI number — DR. DEBORA ANN KUSTRON PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUSTRON
Provider First Name:
DEBORA
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316087950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 BLOOMFIELD AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06095-2809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-683-2352
Provider Business Mailing Address Fax Number:
860-683-2352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 BLOOMFIELD AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06095-2809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-683-2352
Provider Business Practice Location Address Fax Number:
860-683-2352
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  002140 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 002140 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002140 . This is a "PSYCHOLOGIST LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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