=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184223091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WILLIAM MASON MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2020
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 PEGASUS CT STE 500
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22602-4596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1102 CARRIE WAY
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-671-6787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0704011758
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------