Healthcare Provider Details

I. General information

NPI: 1316087950
Provider Name (Legal Business Name): DEBORA ANN KUSTRON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BLOOMFIELD AVE 2ND FLOOR
WINDSOR CT
06095-2809
US

IV. Provider business mailing address

61 BLOOMFIELD AVE 2ND FLOOR
WINDSOR CT
06095-2809
US

V. Phone/Fax

Practice location:
  • Phone: 860-683-2352
  • Fax: 860-683-2352
Mailing address:
  • Phone: 860-683-2352
  • Fax: 860-683-2352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002140
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number002140
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: