Provider Demographics
NPI:1780901983
Name:MASON, DERRICK A (LMFT)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:A
Last Name:MASON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 ASHLEY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2449
Mailing Address - Country:US
Mailing Address - Phone:270-904-6567
Mailing Address - Fax:
Practice Address - Street 1:1048 ASHLEY ST STE 201
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2449
Practice Address - Country:US
Practice Address - Phone:270-904-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY09-013106H00000X
KY106719106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist