Provider Demographics
NPI:1316087950
Name:KUSTRON, DEBORA ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DEBORA
Middle Name:ANN
Last Name:KUSTRON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:860-683-2352
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:860-683-2352
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002140103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002140OtherPSYCHOLOGIST LICENSE