Provider Demographics
NPI:1780428979
Name:SHALLOW, MASON P
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:P
Last Name:SHALLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-1550
Mailing Address - Country:US
Mailing Address - Phone:715-362-5745
Mailing Address - Fax:715-362-2819
Practice Address - Street 1:PO BOX 1550
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-1550
Practice Address - Country:US
Practice Address - Phone:715-362-5745
Practice Address - Fax:715-362-2819
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20605-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)