Provider Demographics
NPI:1295239291
Name:MASON, DERRICK L (CDCA)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:L
Last Name:MASON
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ORIOLE PL SW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-3638
Mailing Address - Country:US
Mailing Address - Phone:330-881-0601
Mailing Address - Fax:
Practice Address - Street 1:605 ORIOLE PL SW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-3638
Practice Address - Country:US
Practice Address - Phone:330-881-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH162683OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD