MEDICARE: MICHAEL WILLIAM VINCENT MACKIE PH.D

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	103TC0700X	Clinical Psychologist	PSY30000	CA

General Provider Information

NPI Number	:	1851881379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WILLIAM VINCENT MACKIE PH.D

Provider Business Mailing Address
First Line	:	10700 SANTA MONICA BLVD STE 300
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6587
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10700 SANTA MONICA BLVD STE 300
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6587
Country	:	US
Telephone Number	:	424-465-2840
Fax Number	:

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

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	12/29/2023

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