Provider Demographics
NPI:1467498113
Name:MOCK, WILLIAM L (PHD, LISW-S, LICDC,)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:MOCK
Suffix:
Gender:M
Credentials:PHD, LISW-S, LICDC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14650 DETROIT AVENUE
Mailing Address - Street 2:SUITE LL40
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107
Mailing Address - Country:US
Mailing Address - Phone:216-226-2721
Mailing Address - Fax:216-226-2731
Practice Address - Street 1:14650 DETROIT AVENUE
Practice Address - Street 2:SUITE LL40
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107
Practice Address - Country:US
Practice Address - Phone:216-226-2721
Practice Address - Fax:216-226-2731
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH78002101YA0400X
OH3670103TC0700X
OHI00024801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0274297Medicaid
OH0274297Medicaid