Provider Demographics
NPI:1326623711
Name:GUILLORY, MASON MCCOY (MT)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:MCCOY
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:MASON
Other - Middle Name:MCCOY
Other - Last Name:FIRESTONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:1200 NE 65TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-6724
Practice Address - Country:US
Practice Address - Phone:260-522-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61144991225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist