MEDICARE: MATTHEW CLARK MASON LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	101YA0400X	MN

General Provider Information

NPI Number	:	1235945791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW CLARK MASON LADC

Provider Business Mailing Address
First Line	:	7801 E BUSH LAKE RD STE 400
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55439-3113
Country	:	US
Telephone Number	:	612-481-9063
Fax Number	:

Provider Business Practice Location Address
First Line	:	7801 E BUSH LAKE RD
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55439-3120
Country	:	US
Telephone Number	:	952-479-4261
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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