Provider Demographics
NPI:1952421760
Name:MASON, KATHALEEN GAYLE (BA CACI, CCJP)
Entity Type:Individual
Prefix:MS
First Name:KATHALEEN
Middle Name:GAYLE
Last Name:MASON
Suffix:
Gender:F
Credentials:BA CACI, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8080 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-8942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1162
Practice Address - Country:US
Practice Address - Phone:231-627-9917
Practice Address - Fax:231-627-2531
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802069569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker