Healthcare Provider Details

I. General information

NPI: 1053001115
Provider Name (Legal Business Name): MASON UNDERWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 FAIRGROVE AVE STE E
HAMILTON OH
45011-1930
US

IV. Provider business mailing address

1910 FAIRGROVE AVE STE E
HAMILTON OH
45011-1930
US

V. Phone/Fax

Practice location:
  • Phone: 513-795-7557
  • Fax:
Mailing address:
  • Phone: 513-795-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.2304869-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: