Provider Demographics
NPI:1053056234
Name:MASON, CICELY RENEE
Entity Type:Individual
Prefix:
First Name:CICELY
Middle Name:RENEE
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8348 LITTLE RD # 177
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-4919
Mailing Address - Country:US
Mailing Address - Phone:772-242-3596
Mailing Address - Fax:
Practice Address - Street 1:13498 MARBLE SANDS CT
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669-8510
Practice Address - Country:US
Practice Address - Phone:772-242-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111715700Medicaid