Provider Demographics
NPI:1194710863
Name:MIDDEL, MARCIA MARIE (PHD)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:MARIE
Last Name:MIDDEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 COBBLE DR
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-7813
Mailing Address - Country:US
Mailing Address - Phone:720-291-9792
Mailing Address - Fax:888-537-7171
Practice Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Practice Address - Street 2:224 D. L. INGRAM AVE BLD. 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-904-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1757103TC0700X
PSY.0001757103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P73384Medicare UPIN
CO801478Medicare ID - Type Unspecified