Healthcare Provider Details

I. General information

NPI: 1891063582
Provider Name (Legal Business Name): MARCIA L BRADEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E DALE ST #110
COLORADO SPRINGS CO
80903-4729
US

IV. Provider business mailing address

214 E DALE ST #110
COLORADO SPRINGS CO
80903-4729
US

V. Phone/Fax

Practice location:
  • Phone: 719-633-3773
  • Fax: 719-633-9705
Mailing address:
  • Phone: 719-633-3773
  • Fax: 719-633-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1894
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: