Provider Demographics
NPI:1467339085
Name:MASON-DICKENS, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MASON-DICKENS
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 1:302 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:NC
Mailing Address - Zip Code:27832-9784
Mailing Address - Country:US
Mailing Address - Phone:252-578-8334
Mailing Address - Fax:
Practice Address - Street 1:412 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-2320
Practice Address - Country:US
Practice Address - Phone:252-578-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA13642251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health