Provider Demographics
NPI:1679235899
Name:NORDMAN, MASON RUSSELL (LGSW)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:RUSSELL
Last Name:NORDMAN
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 HARBOR LN N STE 105
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5109
Mailing Address - Country:US
Mailing Address - Phone:763-559-1640
Mailing Address - Fax:763-559-1617
Practice Address - Street 1:3021 HARBOR LN N STE 105
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5109
Practice Address - Country:US
Practice Address - Phone:763-559-1640
Practice Address - Fax:763-559-1617
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29338104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker