Provider Demographics
NPI:1417980269
Name:DUSTIN, KRISTINE (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DUSTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 DUTCHMASTER DR
Mailing Address - Street 2:
Mailing Address - City:FEEDING HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:01030-2624
Mailing Address - Country:US
Mailing Address - Phone:413-789-7774
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10246151041C0700X
CT0043471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA62-00204OtherEVERCARE
MAP20113Medicare ID - Type Unspecified