Provider Demographics
NPI:1265622211
Name:HEPOLA, MARK G (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:HEPOLA
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 FORSYTH BLVD STE 2300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1806
Mailing Address - Country:US
Mailing Address - Phone:180-067-7123
Mailing Address - Fax:
Practice Address - Street 1:11800 W 49TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2176
Practice Address - Country:US
Practice Address - Phone:303-463-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01094422235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist