MEDICARE: KATRINA MARIE MASON EARLY CHILDHOOD

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1295971901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA MARIE MASON EARLY CHILDHOOD

Provider Business Mailing Address
First Line	:	9906 S SANGAMON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2209
Country	:	US
Telephone Number	:	773-750-4561
Fax Number	:

Provider Business Practice Location Address
First Line	:	9906 S SANGAMON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2209
Country	:	US
Telephone Number	:	773-750-4561
Fax Number	:

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

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	12/30/2008

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