Healthcare Provider Details

I. General information

NPI: 1497320311
Provider Name (Legal Business Name): MASON DRAJER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5257 W BROWN ST
GLENDALE AZ
85302-1613
US

IV. Provider business mailing address

5257 W BROWN ST
GLENDALE AZ
85302-1613
US

V. Phone/Fax

Practice location:
  • Phone: 574-807-5928
  • Fax:
Mailing address:
  • Phone: 574-807-5928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA14013
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: