Healthcare Provider Details

I. General information

NPI: 1710841952
Provider Name (Legal Business Name): MASON LANE CLOUD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4013 N RIDGE RD
WICHITA KS
67205-8857
US

IV. Provider business mailing address

4013 N RIDGE RD
WICHITA KS
67205-8857
US

V. Phone/Fax

Practice location:
  • Phone: 316-706-3709
  • Fax:
Mailing address:
  • Phone: 316-706-3709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number03823-T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: