MEDICARE: MASON RICHARD PACEK LMFT

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	101YM0800X	Mental Health Counselor
2	106H00000X	Marriage & Family Therapist	MFT001821	GA

General Provider Information

NPI Number	:	1831777440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MASON RICHARD PACEK LMFT

Provider Business Mailing Address
First Line	:	1811 GREEN CIR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2734
Country	:	US
Telephone Number	:	229-244-9688
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 GREEN CIR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2734
Country	:	US
Telephone Number	:	864-247-5263
Fax Number	:

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

Provider Enumeration Date	:	04/02/2021
Last Update Date	:	11/11/2021

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