Provider Demographics
NPI:1750383006
Name:MASON, DOUGLAS J (PSYD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MASON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26540 ACE AVE STE E-106
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-8279
Mailing Address - Country:US
Mailing Address - Phone:352-530-2170
Mailing Address - Fax:352-530-2180
Practice Address - Street 1:26540 ACE AVE STE E-106
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-530-2317
Practice Address - Fax:352-530-2180
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
FLPY6497103T00000X, 103G00000X
FLSW4261104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54884OtherBLUE CROSS PROVIDER NUMBE
FL54884OtherBLUE CROSS PROVIDER NUMBE
FL54884OtherBLUE CROSS PROVIDER NUMBE
FL320080992OtherGROUP TAX ID NUMBER
FL54884ZMedicare ID - Type UnspecifiedINDIV PROVIDER NUMBER