Provider Demographics
NPI:1043091150
Name:MASON, DYLAN (PROVISIONAL BCABA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:PROVISIONAL BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 S KIRKWOOD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6166
Mailing Address - Country:US
Mailing Address - Phone:314-806-0735
Mailing Address - Fax:
Practice Address - Street 1:338 S KIRKWOOD RD STE 103
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6166
Practice Address - Country:US
Practice Address - Phone:314-806-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023041335103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst