Provider Demographics
NPI:1376662056
Name:MASON-MOORE, DEBORAH (MS)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:MASON-MOORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3041
Mailing Address - Country:US
Mailing Address - Phone:952-925-5343
Mailing Address - Fax:952-925-5343
Practice Address - Street 1:5009 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 136
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3041
Practice Address - Country:US
Practice Address - Phone:952-925-5343
Practice Address - Fax:952-925-5343
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80641041C0700X
MN75106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist