Provider Demographics
NPI:1073787446
Name:MASON, ANGIE MARIE (DI)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:MARIE
Last Name:MASON
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 KING RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-6688
Mailing Address - Country:US
Mailing Address - Phone:270-623-8302
Mailing Address - Fax:
Practice Address - Street 1:846 KING RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-6688
Practice Address - Country:US
Practice Address - Phone:270-623-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1721OtherFIRST STEPS