Healthcare Provider Details

I. General information

NPI: 1548420474
Provider Name (Legal Business Name): MARLA J SOUDER PSY.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S LANDMARK AVE
BLOOMINGTON IN
47403-5000
US

IV. Provider business mailing address

2599 COUNTY ROAD 72
AUBURN IN
46706-2271
US

V. Phone/Fax

Practice location:
  • Phone: 812-269-3214
  • Fax: 317-520-8200
Mailing address:
  • Phone: 260-615-9971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20042225A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042225A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: