Provider Demographics
NPI:1508949025
Name:HEDGES, MARK STEPHEN (LP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:HEDGES
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 228
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4114
Mailing Address - Country:US
Mailing Address - Phone:605-229-1500
Mailing Address - Fax:605-229-4357
Practice Address - Street 1:202 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 228
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4114
Practice Address - Country:US
Practice Address - Phone:605-229-1500
Practice Address - Fax:605-229-4357
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLP 129103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6552010Medicaid
SD6552010Medicaid