Provider Demographics
NPI:1619249158
Name:MACKIE, KENNETH (LCSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MACKIE
Suffix:
Gender:M
Credentials:LCSW
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 579
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0579
Mailing Address - Country:US
Mailing Address - Phone:541-766-6767
Mailing Address - Fax:
Practice Address - Street 1:4185 SW RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1783
Practice Address - Country:US
Practice Address - Phone:541-766-6767
Practice Address - Fax:541-766-6186
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL70801041C0700X
MTSWP-LCPC-LIC-8142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical