Provider Demographics
NPI:1952571655
Name:MASON, ANNETTE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:MASON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 LONGFIELD LANE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH JUNCTION
Mailing Address - State:WV
Mailing Address - Zip Code:25442
Mailing Address - Country:US
Mailing Address - Phone:304-876-3572
Mailing Address - Fax:
Practice Address - Street 1:110 MORDINGTON AVENUE
Practice Address - Street 2:JEFFERSON COUNTY BOARD OF EDUCATION
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414
Practice Address - Country:US
Practice Address - Phone:304-725-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT000689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156312000Medicaid