MEDICARE: CHARLES ALLEN MASON MA MCAP

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	MCAP100879	FL

General Provider Information

NPI Number	:	1821782723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES ALLEN MASON MA MCAP

Provider Business Mailing Address
First Line	:	528 ELLIOT DR
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-4016
Country	:	US
Telephone Number	:	321-536-2690
Fax Number	:

Provider Business Practice Location Address
First Line	:	4320 S HOPKINS AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6610
Country	:	US
Telephone Number	:	352-505-2432
Fax Number	:

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

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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