Provider Demographics
NPI:1811587678
Name:MASON, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 OAK FOREST CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-3735
Mailing Address - Country:US
Mailing Address - Phone:301-885-9752
Mailing Address - Fax:
Practice Address - Street 1:5823 OAK FOREST CT
Practice Address - Street 2:
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-3735
Practice Address - Country:US
Practice Address - Phone:301-885-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician