Provider Demographics
NPI:1841738309
Name:WORSHAM, MASON DEAN (DPT)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:DEAN
Last Name:WORSHAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1809
Mailing Address - Country:US
Mailing Address - Phone:229-336-1115
Mailing Address - Fax:
Practice Address - Street 1:130 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1809
Practice Address - Country:US
Practice Address - Phone:229-336-1115
Practice Address - Fax:229-336-1151
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program