Healthcare Provider Details

I. General information

NPI: 1649575341
Provider Name (Legal Business Name): KIRSTEN MARIE MASON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FOLSOM PRISON RD
REPRESA CA
95671-3172
US

IV. Provider business mailing address

6884 SCHINDLER RD
NEWCASTLE CA
95658-9437
US

V. Phone/Fax

Practice location:
  • Phone: 916-985-8610
  • Fax:
Mailing address:
  • Phone: 925-768-7662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: