Healthcare Provider Details

I. General information

NPI: 1194245340
Provider Name (Legal Business Name): ELIZABETH LANE MASON BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 S HIGHWAY 69
WAGONER OK
74467-9310
US

IV. Provider business mailing address

28849 E 749 RD
WAGONER OK
74467-6847
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-3006
  • Fax: 918-777-9016
Mailing address:
  • Phone: 918-346-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: