Provider Demographics
NPI:1023653177
Name:MASON, OCTIAVIA SHARNEA (ALC)
Entity type:Individual
Prefix:MISS
First Name:OCTIAVIA
Middle Name:SHARNEA
Last Name:MASON
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BARRETT RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6906
Mailing Address - Country:US
Mailing Address - Phone:334-267-9094
Mailing Address - Fax:
Practice Address - Street 1:330 OLD HAMBURG RD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:AL
Practice Address - Zip Code:36786-2614
Practice Address - Country:US
Practice Address - Phone:334-628-2651
Practice Address - Fax:334-628-2656
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC3432AMedicaid