Provider Demographics
NPI:1275783078
Name:MASON, DENISE SIMONE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:SIMONE
Last Name:MASON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:SIMONE
Other - Last Name:MEDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9635 SOUTHERN PINE BLVD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-5558
Mailing Address - Country:US
Mailing Address - Phone:704-258-4330
Mailing Address - Fax:
Practice Address - Street 1:9635 SOUTHERN PINE BLVD
Practice Address - Street 2:SUITE 127
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-5558
Practice Address - Country:US
Practice Address - Phone:704-258-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0074781041C0700X
FLSW104981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007948Medicaid