Provider Demographics
NPI:1740798081
Name:YODER, MASON BRAIN
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:BRAIN
Last Name:YODER
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 1:1603 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-8786
Mailing Address - Country:US
Mailing Address - Phone:330-554-4009
Mailing Address - Fax:
Practice Address - Street 1:1603 STURBRIDGE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-8786
Practice Address - Country:US
Practice Address - Phone:330-554-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171M00000X
OHCDCA.172114101YA0400X
OH101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0458924Medicaid
OH0357485Medicaid