Provider Demographics
NPI:1215798996
Name:MASON, SELENA (CASAC-T)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2488 GRAND CONCOURSE RM 417
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5206
Mailing Address - Country:US
Mailing Address - Phone:718-584-7204
Mailing Address - Fax:
Practice Address - Street 1:2488 GRAND CONCOURSE RM 417
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5206
Practice Address - Country:US
Practice Address - Phone:718-584-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38491101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)