Provider Demographics
NPI:1245310325
Name:OTOUPAL, NAN NELL (LIC CLIN SOC WORKER)
Entity type:Individual
Prefix:MRS
First Name:NAN
Middle Name:NELL
Last Name:OTOUPAL
Suffix:
Gender:F
Credentials:LIC CLIN SOC WORKER
Other - Prefix:MS
Other - First Name:NAN
Other - Middle Name:NELL
Other - Last Name:OTOUPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW LMSW
Mailing Address - Street 1:102 WONDER WORLD DR # 304-146
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6076
Mailing Address - Country:US
Mailing Address - Phone:719-501-3337
Mailing Address - Fax:
Practice Address - Street 1:102 WONDER WORLD DR # 304-146
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6076
Practice Address - Country:US
Practice Address - Phone:719-501-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164304104Medicaid
TX0071MEOtherBLUE CROSS BLUE SHIELD
TX0071MEOtherBLUE CROSS BLUE SHIELD
TXQ52776Medicare UPIN