Provider Demographics
NPI:1962980771
Name:POEPPE, MARK R (PSYD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:POEPPE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12951 UNIVERSITY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8293
Mailing Address - Country:US
Mailing Address - Phone:515-575-3180
Mailing Address - Fax:
Practice Address - Street 1:12951 UNIVERSITY AVE STE 204
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8293
Practice Address - Country:US
Practice Address - Phone:515-575-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091847103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist