Provider Demographics
NPI:1639588643
Name:BRAD W HOUGHTON PSYD LP LLC
Entity Type:Organization
Organization Name:BRAD W HOUGHTON PSYD LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HOUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD LP
Authorized Official - Phone:612-308-7038
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1532
Mailing Address - Country:US
Mailing Address - Phone:651-645-8300
Mailing Address - Fax:651-645-4603
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1532
Practice Address - Country:US
Practice Address - Phone:651-645-8300
Practice Address - Fax:651-645-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4812305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service