Provider Demographics
NPI:1013556158
Name:MAZUCCI-MAMBALA, MICHAEL J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MAZUCCI-MAMBALA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 VONDERBURG DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6072
Mailing Address - Country:US
Mailing Address - Phone:813-881-1000
Mailing Address - Fax:
Practice Address - Street 1:510 VONDERBURG DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6072
Practice Address - Country:US
Practice Address - Phone:813-881-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW166471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty