1952421760 NPI number — MS. KATHALEEN GAYLE MASON BA CACI, CCJP

Table of content: MS. KATHALEEN GAYLE MASON BA CACI, CCJP (NPI 1952421760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952421760 NPI number — MS. KATHALEEN GAYLE MASON BA CACI, CCJP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASON
Provider First Name:
KATHALEEN
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA CACI, CCJP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952421760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8080 RIDGEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEBOYGAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49721-8942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CHEBOYGAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49721-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-627-9917
Provider Business Practice Location Address Fax Number:
231-627-2531
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6802069569 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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