Provider Demographics
NPI:1619404860
Name:HOLT, MATTHEW JASON (LCPC-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JASON
Last Name:HOLT
Suffix:
Gender:M
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 MAIN STREET, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073
Mailing Address - Country:US
Mailing Address - Phone:207-490-6600
Mailing Address - Fax:
Practice Address - Street 1:469 MAIN STREET, SUITE 201
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073
Practice Address - Country:US
Practice Address - Phone:207-490-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health