Provider Demographics
NPI:1750471314
Name:GUSTAVSON-MATTEK, KELLY M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:GUSTAVSON-MATTEK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:GUSTAVSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1005
Mailing Address - Country:US
Mailing Address - Phone:262-741-3200
Mailing Address - Fax:262-741-3217
Practice Address - Street 1:1910 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4454
Practice Address - Country:US
Practice Address - Phone:262-741-3200
Practice Address - Fax:262-741-3217
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2533-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40938700Medicaid