Provider Demographics
NPI:1801438510
Name:CALDWELL, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 SHALE DR
Mailing Address - Street 2:
Mailing Address - City:JARRELL
Mailing Address - State:TX
Mailing Address - Zip Code:76537-1376
Mailing Address - Country:US
Mailing Address - Phone:512-632-4117
Mailing Address - Fax:
Practice Address - Street 1:7000 N MOPAC EXPY STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3013
Practice Address - Country:US
Practice Address - Phone:512-632-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical