Healthcare Provider Details

I. General information

NPI: 1457216103
Provider Name (Legal Business Name): MACKENZIE LAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6444 FAIRWAY AVE SE STE 100
SALEM OR
97306-3073
US

IV. Provider business mailing address

4090 BECK AVE SE
SALEM OR
97317-5617
US

V. Phone/Fax

Practice location:
  • Phone: 971-901-2731
  • Fax: 971-901-3065
Mailing address:
  • Phone: 503-999-1536
  • Fax: 503-999-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: