Healthcare Provider Details

I. General information

NPI: 1780375121
Provider Name (Legal Business Name): REBECCA FAGEN HOUGHTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 7TH ST STE 200
BLOOMINGTON IN
47404-3839
US

IV. Provider business mailing address

120 W 7TH ST STE 200
BLOOMINGTON IN
47404-3839
US

V. Phone/Fax

Practice location:
  • Phone: 812-269-6966
  • Fax:
Mailing address:
  • Phone: 812-269-5304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88002571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: