Provider Demographics
NPI:1053504936
Name:MASON, MODESTYNE YVONNE (OTR L)
Entity Type:Individual
Prefix:MS
First Name:MODESTYNE
Middle Name:YVONNE
Last Name:MASON
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S HIGHLAND FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-1952
Mailing Address - Country:US
Mailing Address - Phone:803-786-5949
Mailing Address - Fax:
Practice Address - Street 1:201 S HIGHLAND FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-1952
Practice Address - Country:US
Practice Address - Phone:803-786-5949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC792225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist