Healthcare Provider Details

I. General information

NPI: 1003862160
Provider Name (Legal Business Name): MAKIKO MATSUOKA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 DRESSER RD
SCARBOROUGH ME
04074-9767
US

IV. Provider business mailing address

PO BOX 6568
SCARBOROUGH ME
04070-6568
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-9539
  • Fax:
Mailing address:
  • Phone: 207-907-9539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCC3223
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL2717
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: