Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist | ||
N | 103TC1900X | Counseling Psychologist | ||
N | 103TC2200X | Clinical Child & Adolescent Psychologist | ||
N | 103TF0000X | Family Psychologist |
NPI | 1043789688 |
---|---|
Provider Name | Dr. Dynesha Dione Mason-Grissom |
First Address | Champaign, IL 61821-7038 |
Second Address | Champaign, IL 61821-7038 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2018 |
Last Update Date | 21/01/2020 |