Provider Demographics
NPI:1114425055
Name:CALDER, MARCIE CAROL (EDS)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:CAROL
Last Name:CALDER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:MARCIE
Other - Middle Name:CAROL
Other - Last Name:BADHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4535 SW 68TH COURT CIR APT 7
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6857
Mailing Address - Country:US
Mailing Address - Phone:801-319-8821
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE # 103-104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5826
Practice Address - Country:US
Practice Address - Phone:786-655-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-40040103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid