Provider Demographics
NPI:1295920296
Name:MASON, BRIAN O (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:O
Last Name:MASON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5309
Mailing Address - Country:US
Mailing Address - Phone:815-332-6027
Mailing Address - Fax:815-332-6027
Practice Address - Street 1:8616 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5309
Practice Address - Country:US
Practice Address - Phone:815-332-6027
Practice Address - Fax:815-332-6027
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490077511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149007751OtherLICENSED CLINICAL SOCIAL WORKER