Provider Demographics
NPI:1790837409
Name:HAMILTON - MASON, JOHNNIE (PHD)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:HAMILTON - MASON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136
Mailing Address - Country:US
Mailing Address - Phone:617-364-4403
Mailing Address - Fax:
Practice Address - Street 1:42 SEAVERNS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-2884
Practice Address - Country:US
Practice Address - Phone:617-521-3911
Practice Address - Fax:614-521-3980
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1034941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical