Provider Demographics
NPI:1235945791
Name:MASON, MATTHEW CLARK (LADC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
Last Name:MASON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 E BUSH LAKE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3113
Mailing Address - Country:US
Mailing Address - Phone:612-481-9063
Mailing Address - Fax:
Practice Address - Street 1:7801 E BUSH LAKE RD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-3120
Practice Address - Country:US
Practice Address - Phone:952-479-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty