Provider Demographics
NPI:1790877090
Name:MACKAY, RUSSELL P
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:MACKAY
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 1:1003 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5601
Mailing Address - Country:US
Mailing Address - Phone:801-380-3914
Mailing Address - Fax:
Practice Address - Street 1:434 MASSACHUSETTS AVE STE 501
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3522
Practice Address - Country:US
Practice Address - Phone:339-666-8516
Practice Address - Fax:617-807-0958
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10002806101YM0800X
UT5935490-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health