MEDICARE: KEN MACKIE, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1780521633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEN MACKIE, LLC

Provider Business Mailing Address
First Line	:	2600 NW CENTURY DR APT 303
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97330-4736
Country	:	US
Telephone Number	:	541-250-0243
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 NW CENTURY DR APT 303
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97330-4736
Country	:	US
Telephone Number	:	541-250-0243
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/THERAPIST
Name	:	KEN MACKIE
Credential	:	LCSW
Telephone Number	:	530-262-0517

Provider Enumeration Date	:	04/29/2026
Last Update Date	:	05/30/2026

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