Provider Demographics
NPI:1700396793
Name:MACKIE ENTERPRISES LLC
Entity Type:Organization
Organization Name:MACKIE ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MACKIE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:971-207-5010
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-09-29101YA0400X
ORC2538101YM0800X
ORC2348261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid