Provider Demographics
NPI:1326207598
Name:MASON, LISA MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIE
Last Name:MASON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:COSGROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1305 ALEXANDER STREET
Mailing Address - Street 2:RIVERSIDE NURSING AND REHABILITATION CENTER
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-736-5012
Mailing Address - Fax:
Practice Address - Street 1:1305 ALEXANDER STREET
Practice Address - Street 2:RIVERSIDE NURSING AND REHABILITATION CENTER
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:360-736-5012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist