Provider Demographics
NPI:1740631589
Name:MASON, MIKKI LACHELLE
Entity type:Individual
Prefix:
First Name:MIKKI
Middle Name:LACHELLE
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKKI
Other - Middle Name:LACHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8905 E JEFFERSON AVE
Mailing Address - Street 2:APT 404
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-4182
Mailing Address - Country:US
Mailing Address - Phone:734-489-3563
Mailing Address - Fax:
Practice Address - Street 1:8905 E JEFFERSON AVE
Practice Address - Street 2:APT 404
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-4182
Practice Address - Country:US
Practice Address - Phone:734-489-3563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other