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NPI Code Detail

MEDICARE: MR. MARK PATRICK MASTERSON MSW

MEDICARE: MR. MARK PATRICK MASTERSON MSW
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
1101YM0800XMental Health CounselorLW00004819WA

General Provider Information

NPI Number : 1841203395
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARK PATRICK MASTERSON MSW
Provider Business Mailing Address
First Line : 3847 NE 23RD AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97212-1449
Country : US
Telephone Number : 503-287-6513
Fax Number :
Provider Business Practice Location Address
First Line : 12607 SE MILL PLAIN BLVD
Second Line :
City : VANCOUVER
State : WA
Zip : 98684-6055
Country : US
Telephone Number : 360-896-4460
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/15/2006
Last Update Date : 07/08/2007

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