Provider Demographics
NPI:1518523406
Name:MCDONALD, MASON D
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:D
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12350 S 800 E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9712
Mailing Address - Country:US
Mailing Address - Phone:801-998-8428
Mailing Address - Fax:
Practice Address - Street 1:12350 S 800 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9712
Practice Address - Country:US
Practice Address - Phone:801-998-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician