Provider Demographics
NPI:1922778810
Name:GREENWOOD, MASON TYLOR (LPC, NCC, PEL)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:TYLOR
Last Name:GREENWOOD
Suffix:
Gender:M
Credentials:LPC, NCC, PEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 S 36TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5801
Mailing Address - Country:US
Mailing Address - Phone:217-228-6194
Mailing Address - Fax:217-209-0201
Practice Address - Street 1:195 S 36TH ST STE 400
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-5801
Practice Address - Country:US
Practice Address - Phone:217-228-6194
Practice Address - Fax:217-209-0201
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015884101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.015884OtherPRIVATE PRACTICE