MEDICARE: IAN DOUGLAS MACKELVIE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	62012	CA
2	1041C0700X	Clinical Social Worker	LW61573386	WA
3	1041C0700X	Clinical Social Worker	84796	CA

General Provider Information

NPI Number	:	1659651370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN DOUGLAS MACKELVIE LCSW

Provider Business Mailing Address
First Line	:	1817 QUEEN ANNE AVE N STE 202
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2876
Country	:	US
Telephone Number	:	707-440-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 QUEEN ANNE AVE N STE 202
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2876
Country	:	US
Telephone Number	:	707-440-9288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	08/20/2025

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