Provider Demographics
NPI:1417694498
Name:MASON, CHUCK L (BS)
Entity Type:Individual
Prefix:
First Name:CHUCK
Middle Name:L
Last Name:MASON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:L
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1836 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2964
Mailing Address - Country:US
Mailing Address - Phone:217-508-8080
Mailing Address - Fax:217-512-2288
Practice Address - Street 1:1836 VICTORIA LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2964
Practice Address - Country:US
Practice Address - Phone:217-508-8080
Practice Address - Fax:217-512-2288
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health