Healthcare Provider Details

I. General information

NPI: 1922190834
Provider Name (Legal Business Name): MASTOR MENTAL HEALTH AND ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 JOE V KNOX AVE SUITE F
MOORESVILLE NC
28117-7911
US

IV. Provider business mailing address

206 JOE V KNOX AVE SUITE F
MOORESVILLE NC
28117-7911
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-6500
  • Fax: 704-662-6503
Mailing address:
  • Phone: 704-662-6500
  • Fax: 704-662-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON ELIA MASTOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-662-6500