Healthcare Provider Details

I. General information

NPI: 1881433506
Provider Name (Legal Business Name): MASON E VANROSSUM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 PILGRIM WAY # 1300-A
GREEN BAY WI
54304-5280
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 920-610-5119
  • Fax: 920-610-5120
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11795
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number7475-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: