Provider Demographics
NPI:1194293704
Name:MASON, VIRGIE LEE
Entity type:Individual
Prefix:
First Name:VIRGIE
Middle Name:LEE
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 OAK ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-4337
Mailing Address - Country:US
Mailing Address - Phone:216-201-2655
Mailing Address - Fax:
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-4337
Practice Address - Country:US
Practice Address - Phone:216-201-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOHIOMHASMedicaid