Provider Demographics
NPI:1134356520
Name:MASON, STACY (MA)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3774 RIDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-3169
Mailing Address - Country:US
Mailing Address - Phone:610-489-3340
Mailing Address - Fax:610-489-3375
Practice Address - Street 1:3774 RIDGE PIKE
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3169
Practice Address - Country:US
Practice Address - Phone:610-489-3340
Practice Address - Fax:610-489-3375
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA117910103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100753390Medicaid
PA734714Medicare PIN