Provider Demographics
NPI:1265217103
Name:MULLENIX, MATT THOMAS
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:THOMAS
Last Name:MULLENIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 LOTUS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6450
Mailing Address - Country:US
Mailing Address - Phone:757-255-8282
Mailing Address - Fax:
Practice Address - Street 1:900 COMMONWEALTH PL STE 200-1045
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4517
Practice Address - Country:US
Practice Address - Phone:757-255-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health