Provider Demographics
NPI:1023481033
Name:MUSTON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MUSTON
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 1:1230 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4883
Mailing Address - Country:US
Mailing Address - Phone:262-789-1191
Mailing Address - Fax:
Practice Address - Street 1:1230 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4883
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5604-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional