Healthcare Provider Details

I. General information

NPI: 1154218808
Provider Name (Legal Business Name): MATTHEW WAYNE MULOCK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 MARINER BLVD
SPRING HILL FL
34609-2467
US

IV. Provider business mailing address

22176 CROOM RD
BROOKSVILLE FL
34601-4827
US

V. Phone/Fax

Practice location:
  • Phone: 352-606-0323
  • Fax:
Mailing address:
  • Phone: 727-389-0870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW24887
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: