Provider Demographics
NPI:1598163115
Name:MOUTON, NIKIA (LMSW)
Entity Type:Individual
Prefix:
First Name:NIKIA
Middle Name:
Last Name:MOUTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BRIAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 BRIAN DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6537
Practice Address - Country:US
Practice Address - Phone:469-744-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX54476104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker