Provider Demographics
NPI:1326396441
Name:GUSTAVSON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1491 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1914
Mailing Address - Country:US
Mailing Address - Phone:860-456-3215
Mailing Address - Fax:
Practice Address - Street 1:1491 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1914
Practice Address - Country:US
Practice Address - Phone:860-456-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health