Provider Demographics
NPI:1053709667
Name:STANLEY, MASON
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 W SAHARA AVE
Mailing Address - Street 2:APT 1088
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5373
Mailing Address - Country:US
Mailing Address - Phone:575-654-9073
Mailing Address - Fax:
Practice Address - Street 1:2035 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2223
Practice Address - Country:US
Practice Address - Phone:702-386-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13-1182224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant