MEDICARE: MASONA FOFANA RBT

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	106S00000X	Behavior Technician	RBT-21-193614	GA

General Provider Information

NPI Number	:	1609536929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MASONA FOFANA RBT

Provider Business Mailing Address
First Line	:	2265 MARIETTA BLVD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-2027
Country	:	US
Telephone Number	:	478-397-9381
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 PHOENIX BLVD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-5593
Country	:	US
Telephone Number	:	478-397-9381
Fax Number	:

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

Provider Enumeration Date	:	12/28/2021
Last Update Date	:	12/28/2021

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Directions to “ MASONA FOFANA RBT” Practice Location

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