Provider Demographics
NPI:1497910301
Name:MACKIE, ROBERT M
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:M
Last Name:MACKIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 VICTORIAN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2977
Mailing Address - Country:US
Mailing Address - Phone:831-427-1007
Mailing Address - Fax:
Practice Address - Street 1:707 FAIR AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5828
Practice Address - Country:US
Practice Address - Phone:831-427-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSSN