MEDICARE: TYRA MASON

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

General Provider Information

NPI Number	:	1811587678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA MASON

Provider Business Mailing Address
First Line	:	5823 OAK FOREST CT
Second Line	:
City	:	INDIAN HEAD
State	:	MD
Zip	:	20640-3735
Country	:	US
Telephone Number	:	301-885-9752
Fax Number	:

Provider Business Practice Location Address
First Line	:	5823 OAK FOREST CT
Second Line	:
City	:	INDIAN HEAD
State	:	MD
Zip	:	20640-3735
Country	:	US
Telephone Number	:	301-885-9752
Fax Number	:

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

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	01/25/2021

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Directions to “ TYRA MASON ” Practice Location

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