Provider Demographics
NPI:1205813581
Name:MASON, TAMARA LONELLE (MSW LICSW)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:LONELLE
Last Name:MASON
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:CORBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:522 BELTRAMI AVE NW STE 108
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3002
Mailing Address - Country:US
Mailing Address - Phone:218-444-0899
Mailing Address - Fax:
Practice Address - Street 1:522 BELTRAMI AVE NW
Practice Address - Street 2:SUITE 108
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3001
Practice Address - Country:US
Practice Address - Phone:218-444-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN811435800Medicaid
MN811435800Medicaid