Provider Demographics
NPI:1619556834
Name:MASON, TYVISHA C (ACSW)
Entity type:Individual
Prefix:MS
First Name:TYVISHA
Middle Name:C
Last Name:MASON
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 CALIFORNIA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1412
Mailing Address - Country:US
Mailing Address - Phone:707-944-4797
Mailing Address - Fax:
Practice Address - Street 1:260 CALIFRONIA DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-3911
Practice Address - Country:US
Practice Address - Phone:707-944-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99258101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health