Provider Demographics
NPI:1053656413
Name:GOLDER, MARCUS BOYD (LMSW)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:BOYD
Last Name:GOLDER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 E BUTTE RD
Mailing Address - Street 2:
Mailing Address - City:MENAN
Mailing Address - State:ID
Mailing Address - Zip Code:83434-5122
Mailing Address - Country:US
Mailing Address - Phone:208-754-0911
Mailing Address - Fax:
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-524-8004
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW322921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical