MEDICARE: KRISTEN DRIESSE MASON PT

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	225100000X	Physical Therapist	5501	SC

General Provider Information

NPI Number	:	1962607887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN DRIESSE MASON PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	1409 W GEORGIA RD
Second Line	:	STE C
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29680-6419
Country	:	US
Telephone Number	:	864-454-5012
Fax Number	:

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

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	11/09/2015

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