Healthcare Provider Details

I. General information

NPI: 1053656413
Provider Name (Legal Business Name): MARCUS BOYD GOLDER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 W BROADWAY ST STE G
IDAHO FALLS ID
83402-2902
US

IV. Provider business mailing address

1023 E BUTTE RD
MENAN ID
83434-5122
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax: 208-524-8004
Mailing address:
  • Phone: 208-754-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW32292
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: