Healthcare Provider Details

I. General information

NPI: 1396870796
Provider Name (Legal Business Name): STACY W. MASON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MANATEE AVE E
BRADENTON FL
34208-1145
US

IV. Provider business mailing address

15544 W COLONIAL DR
WINTER GARDEN FL
34787-9556
US

V. Phone/Fax

Practice location:
  • Phone: 800-457-4573
  • Fax: 800-443-6422
Mailing address:
  • Phone: 352-504-0340
  • Fax: 800-443-6422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT40366
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT4834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: