Provider Demographics
NPI:1235532011
Name:MAYNARD, MATTHEW (MA MFT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SYLVAN RD S
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4639
Mailing Address - Country:US
Mailing Address - Phone:978-413-5142
Mailing Address - Fax:
Practice Address - Street 1:3 SYLVAN RD S
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4639
Practice Address - Country:US
Practice Address - Phone:978-413-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1708106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist