Healthcare Provider Details

I. General information

NPI: 1295971901
Provider Name (Legal Business Name): KATRINA MARIE MASON EARLY CHILDHOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9906 S SANGAMON ST
CHICAGO IL
60643-2209
US

IV. Provider business mailing address

9906 S SANGAMON ST
CHICAGO IL
60643-2209
US

V. Phone/Fax

Practice location:
  • Phone: 773-750-4561
  • Fax:
Mailing address:
  • Phone: 773-750-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: