Provider Demographics
NPI:1003230723
Name:MASON, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1304
Mailing Address - Country:US
Mailing Address - Phone:913-294-9175
Mailing Address - Fax:913-294-9175
Practice Address - Street 1:310 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1304
Practice Address - Country:US
Practice Address - Phone:913-294-9175
Practice Address - Fax:913-294-9175
Is Sole Proprietor?:No
Enumeration Date:2014-02-17
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101YP1600X101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral