Provider Demographics
NPI:1043382021
Name:MASON, TONI L (PHD)
Entity Type:Individual
Prefix:DR
First Name:TONI
Middle Name:L
Last Name:MASON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 JENNINGS MILL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2579
Mailing Address - Country:US
Mailing Address - Phone:706-316-1908
Mailing Address - Fax:706-316-2062
Practice Address - Street 1:1361 JENNINGS MILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2579
Practice Address - Country:US
Practice Address - Phone:706-316-1908
Practice Address - Fax:706-316-2062
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2674103T00000X, 103TC2200X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10034544OtherAMERIGROUP