Healthcare Provider Details

I. General information

NPI: 1255944211
Provider Name (Legal Business Name): KATHRYN M MASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN MASON

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 NICOLLET AVE # 130
MINNEAPOLIS MN
55408-1629
US

IV. Provider business mailing address

5418 WASHBURN AVE S
MINNEAPOLIS MN
55410-2435
US

V. Phone/Fax

Practice location:
  • Phone: 612-360-7158
  • Fax:
Mailing address:
  • Phone: 612-360-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: