Healthcare Provider Details

I. General information

NPI: 1235532011
Provider Name (Legal Business Name): MATTHEW MAYNARD M.A. MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 EDISON ST
WYCKOFF NJ
07481-2726
US

IV. Provider business mailing address

91 EDISON ST
WYCKOFF NJ
07481-2726
US

V. Phone/Fax

Practice location:
  • Phone: 978-413-5142
  • Fax:
Mailing address:
  • Phone: 978-413-5142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1708
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37FI00179800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: