Provider Demographics
NPI:1114646296
Name:HAVILAND, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HAVILAND
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 1:37 CAPE RD
Mailing Address - Street 2:
Mailing Address - City:SEAL COVE
Mailing Address - State:ME
Mailing Address - Zip Code:04674-4451
Mailing Address - Country:US
Mailing Address - Phone:207-266-5770
Mailing Address - Fax:
Practice Address - Street 1:37 CAPE RD
Practice Address - Street 2:
Practice Address - City:SEAL COVE
Practice Address - State:ME
Practice Address - Zip Code:04674-4451
Practice Address - Country:US
Practice Address - Phone:207-266-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL6762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health