Provider Demographics
NPI:1407134554
Name:DEBORA A. KUSTRON, PSY.D., LLC
Entity Type:Organization
Organization Name:DEBORA A. KUSTRON, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUSTRON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-683-2352
Mailing Address - Street 1:61 BLOOMFIELD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2809
Mailing Address - Country:US
Mailing Address - Phone:860-683-2352
Mailing Address - Fax:
Practice Address - Street 1:61 BLOOMFIELD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2809
Practice Address - Country:US
Practice Address - Phone:860-683-2352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002140103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316087950Medicaid
CT1316087950Medicaid