Healthcare Provider Details

I. General information

NPI: 1780521633
Provider Name (Legal Business Name): KEN MACKIE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 NW CENTURY DR APT 303
CORVALLIS OR
97330-4736
US

IV. Provider business mailing address

2600 NW CENTURY DR APT 303
CORVALLIS OR
97330-4736
US

V. Phone/Fax

Practice location:
  • Phone: 541-250-0243
  • Fax:
Mailing address:
  • Phone: 541-250-0243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KEN MACKIE
Title or Position: MANAGER/THERAPIST
Credential: LCSW
Phone: 530-262-0517