Provider Demographics
NPI:1689331076
Name:MASON, KELSEY REBECCA
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:REBECCA
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 1:2217 KING GEORGE CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5648
Mailing Address - Country:US
Mailing Address - Phone:252-515-2603
Mailing Address - Fax:
Practice Address - Street 1:1420 PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1470
Practice Address - Country:US
Practice Address - Phone:336-560-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician