Basic Information
Provider Information | |||||||||
NPI: | 1295404309 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASON | ||||||||
FirstName: | LASHAVONE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1685 BALDWIN AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483401242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2487063450 | ||||||||
FaxNumber: | 2487063455 | ||||||||
Practice Location | |||||||||
Address1: | 6549 TOWN CENTER DR STE A | ||||||||
Address2: |   | ||||||||
City: | CLARKSTON | ||||||||
State: | MI | ||||||||
PostalCode: | 483464824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003953223 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2021 | ||||||||
LastUpdateDate: | 05/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X |   |   | Y |   | Technologists, Technicians & Other Technical Service Providers | Technician, Other |   | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.