Provider Demographics
NPI:1306395900
Name:MASON, NICOLE LATRELLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LATRELLE
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 1:306 N MAIN ST STE A1A
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2533
Mailing Address - Country:US
Mailing Address - Phone:912-320-4573
Mailing Address - Fax:
Practice Address - Street 1:306 N MAIN ST STE A1A
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2533
Practice Address - Country:US
Practice Address - Phone:912-320-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002444235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist