Healthcare Provider Details

I. General information

NPI: 1841203395
Provider Name (Legal Business Name): MARK PATRICK MASTERSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 SE MILL PLAIN BLVD
VANCOUVER WA
98684-6055
US

IV. Provider business mailing address

3847 NE 23RD AVE
PORTLAND OR
97212-1449
US

V. Phone/Fax

Practice location:
  • Phone: 360-896-4460
  • Fax:
Mailing address:
  • Phone: 503-287-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW00004819
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: