Basic Information
| Provider Information | |||||||||
| NPI: | 1134734569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 534 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494242739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165108019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 BAKER ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494442157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317371335 | ||||||||
| FaxNumber: | 2317370534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1134734569 | 05 | MI | MEDICAID |