Provider Demographics
NPI:1053973040
Name:MAST, WILMA KAY (PCC)
Entity type:Individual
Prefix:
First Name:WILMA
Middle Name:KAY
Last Name:MAST
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6183 COUNTY ROAD 207
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-9024
Mailing Address - Country:US
Mailing Address - Phone:330-473-8358
Mailing Address - Fax:
Practice Address - Street 1:151 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2223
Practice Address - Country:US
Practice Address - Phone:419-774-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1901870101YM0800X
OHE.2102418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health