Healthcare Provider Details

I. General information

NPI: 1700660958
Provider Name (Legal Business Name): ADAM J MACKENZIE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 E RIVERPARK LN STE 220
BOISE ID
83706-6559
US

IV. Provider business mailing address

671 E RIVERPARK LN STE 220
BOISE ID
83706-6559
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-2071
  • Fax: 208-344-2075
Mailing address:
  • Phone: 208-344-2071
  • Fax: 208-344-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1171360
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: