Healthcare Provider Details

I. General information

NPI: 1215831383
Provider Name (Legal Business Name): PHOENIX MASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PHOENIX VALDES

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 LIVE OAK ST OFC 1
EDGEWATER FL
32132-1553
US

IV. Provider business mailing address

509 LIVE OAK ST OFC 1
EDGEWATER FL
32132-1553
US

V. Phone/Fax

Practice location:
  • Phone: 386-663-4495
  • Fax:
Mailing address:
  • Phone: 386-663-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: