Provider Demographics
NPI:1750811618
Name:MASON, BENJAMIN M (SLP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:MASON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 INCA ST UNIT 4117
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1990
Mailing Address - Country:US
Mailing Address - Phone:614-558-1288
Mailing Address - Fax:
Practice Address - Street 1:10184 E I25 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-5445
Practice Address - Country:US
Practice Address - Phone:720-378-6670
Practice Address - Fax:303-557-9701
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22105395Medicaid