Provider Demographics
NPI:1609489624
Name:EDMUNDS, MASON G (OCPSA)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:G
Last Name:EDMUNDS
Suffix:
Gender:M
Credentials:OCPSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1227
Mailing Address - Country:US
Mailing Address - Phone:330-797-0070
Mailing Address - Fax:
Practice Address - Street 1:527 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1227
Practice Address - Country:US
Practice Address - Phone:330-797-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRA.162173405300000X
OHOCPSA.161826405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional