Provider Demographics
NPI:1457170821
Name:MASON, TICA (RN,BSN)
Entity type:Individual
Prefix:
First Name:TICA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4111
Mailing Address - Country:US
Mailing Address - Phone:480-862-3643
Mailing Address - Fax:
Practice Address - Street 1:6302 E QUARTZ ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-0943
Practice Address - Country:US
Practice Address - Phone:480-862-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH10019320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness