Provider Demographics
NPI:1417019399
Name:HOULTON, NANCY LEE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LEE
Last Name:HOULTON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:LEE
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1426 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2411
Mailing Address - Country:US
Mailing Address - Phone:651-646-4060
Mailing Address - Fax:
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-266-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN095718600Medicaid