Provider Demographics
NPI:1609536929
Name:FOFANA, MASONA (RBT)
Entity Type:Individual
Prefix:
First Name:MASONA
Middle Name:
Last Name:FOFANA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 MARIETTA BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2027
Mailing Address - Country:US
Mailing Address - Phone:478-397-9381
Mailing Address - Fax:
Practice Address - Street 1:1800 PHOENIX BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5593
Practice Address - Country:US
Practice Address - Phone:478-397-9381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-193614106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician