Provider Demographics
NPI:1801324850
Name:MASON, WYNEISHA J (MAT, ATC)
Entity type:Individual
Prefix:
First Name:WYNEISHA
Middle Name:J
Last Name:MASON
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:WYNEISHA
Other - Middle Name:JACKEE'
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:305 W 35TH ST APT 306
Mailing Address - Street 2:
Mailing Address - City:STEGER
Mailing Address - State:IL
Mailing Address - Zip Code:60475-1451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10001 S WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1645
Practice Address - Country:US
Practice Address - Phone:773-291-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0040122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer