=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790877090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL P MACKAY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 MASSACHUSETTS AVE STE 501
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 339-666-8516
-----------------------------------------------------
Fax | 617-807-0958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 EASTGATE DR
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84606-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-380-3914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LMHC10002806
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5935490-6009
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------