Provider Demographics
NPI:1275867749
Name:MACKIE, KEITH JOHN (LPC, CADCI)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JOHN
Last Name:MACKIE
Suffix:
Gender:M
Credentials:LPC, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 NE 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5420
Mailing Address - Country:US
Mailing Address - Phone:971-207-5010
Mailing Address - Fax:
Practice Address - Street 1:1134 NE 70TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5420
Practice Address - Country:US
Practice Address - Phone:971-207-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-09-29101YA0400X
ORC2348103TC1900X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
ORR0000WDBCHMedicare Oscar/Certification