Provider Demographics
NPI:1780858498
Name:MASON, PAUL THOMAS (MS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:THOMAS
Last Name:MASON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 W LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8494
Mailing Address - Country:US
Mailing Address - Phone:414-423-5968
Mailing Address - Fax:
Practice Address - Street 1:4036 W LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8494
Practice Address - Country:US
Practice Address - Phone:414-423-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1455-125101YP2500X
WI2820-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39638300Medicaid