Provider Demographics
NPI:1750338265
Name:GASTON, CONNIE (LMLP/LCP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:LMLP/LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3602
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-383-7925
Practice Address - Street 1:934 N WATER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3838
Practice Address - Country:US
Practice Address - Phone:316-660-7500
Practice Address - Fax:316-383-4590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS572103TC0700X
KS212103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2157275OtherCIGNA
KS389911OtherBLUE CROSS BLUE SHIELD
KS9432OtherPREFERRED HEALTH SYSTEMS
KSPV119197OtherAMERICAN PSYCH SYSTEMS