Provider Demographics
NPI:1285856302
Name:HEDGES, MARK (MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HEDGES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10762 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5830
Mailing Address - Country:US
Mailing Address - Phone:623-478-1603
Mailing Address - Fax:
Practice Address - Street 1:10762 W WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5830
Practice Address - Country:US
Practice Address - Phone:623-478-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool