Provider Demographics
NPI:1598035701
Name:OTTO, MATTHEW IRA (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:IRA
Last Name:OTTO
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6835 WOODCREST RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-2946
Mailing Address - Country:US
Mailing Address - Phone:410-997-7288
Mailing Address - Fax:410-997-2880
Practice Address - Street 1:10774 HICKORY RIDGE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3646
Practice Address - Country:US
Practice Address - Phone:410-997-7288
Practice Address - Fax:410-997-2880
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional