Provider Demographics
NPI:1174897516
Name:CALDWELL, MARVA M (MA,PMH 1020)
Entity type:Individual
Prefix:MRS
First Name:MARVA
Middle Name:M
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MA,PMH 1020
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 LOOKOUT PL
Mailing Address - Street 2:150
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-8440
Mailing Address - Country:US
Mailing Address - Phone:407-622-1770
Mailing Address - Fax:
Practice Address - Street 1:220 LOOKOUT PL
Practice Address - Street 2:150
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-8440
Practice Address - Country:US
Practice Address - Phone:407-622-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health