Basic Information
| Provider Information | |||||||||
| NPI: | 1851332423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEPOLA | ||||||||
| FirstName: | MARIE | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 CHESHIRE LN N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883339152 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 W ROMNEYA DR | ||||||||
| Address2: | 205 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928011830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149562881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AU1279 | CA | X | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | HA2535 | CA | X | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | AU0012790 | 05 | CA | MEDICAID |