Provider Demographics
NPI:1629320643
Name:MASON, LARINA SMITH (PT)
Entity Type:Individual
Prefix:MRS
First Name:LARINA
Middle Name:SMITH
Last Name:MASON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 N CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-8064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2222 S FRONTAGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5271
Practice Address - Country:US
Practice Address - Phone:601-456-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 3041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist