Provider Demographics
NPI:1003794454
Name:MASON, TYRELL
Entity type:Individual
Prefix:
First Name:TYRELL
Middle Name:
Last Name:MASON
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 1:7113 BENTZ ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3992
Mailing Address - Country:US
Mailing Address - Phone:689-290-5043
Mailing Address - Fax:
Practice Address - Street 1:7113 BENTZ ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-3992
Practice Address - Country:US
Practice Address - Phone:689-290-5043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000041687900171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator