Provider Demographics
NPI:1003983347
Name:HEDGEPETH, MARK R (LCSW R)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HEDGEPETH
Suffix:
Gender:M
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 B MILTON ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-789-8291
Mailing Address - Fax:315-789-8291
Practice Address - Street 1:58 B MILTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-789-8291
Practice Address - Fax:315-789-8291
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04017011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC7107Medicare ID - Type Unspecified
P35789Medicare UPIN