Provider Demographics
NPI:1003862160
Name:MATSUOKA, MAKIKO (LCPC)
Entity Type:Individual
Prefix:
First Name:MAKIKO
Middle Name:
Last Name:MATSUOKA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6568
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04070-6568
Mailing Address - Country:US
Mailing Address - Phone:207-907-9539
Mailing Address - Fax:
Practice Address - Street 1:34 DRESSER RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9767
Practice Address - Country:US
Practice Address - Phone:207-907-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL2717101YP2500X
MECC3223101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098304OtherANTHEM LEGACY NUMBER
ME431733799Medicaid