Provider Demographics
NPI:1245013382
Name:MASON, SHONTAVIA (MS, PLPC)
Entity type:Individual
Prefix:MS
First Name:SHONTAVIA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:MS, PLPC
Other - Prefix:MS
Other - First Name:SHONTAVIA
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, PLPC
Mailing Address - Street 1:523 SAPPHIRE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1889
Mailing Address - Country:US
Mailing Address - Phone:314-368-2409
Mailing Address - Fax:314-442-4139
Practice Address - Street 1:10828 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-1508
Practice Address - Country:US
Practice Address - Phone:314-368-2409
Practice Address - Fax:314-442-4139
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023015719103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy