Provider Demographics
NPI:1790877090
Name:MACKAY, RUSSELL P (SSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:MACKAY
Suffix:
Gender:M
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5601
Mailing Address - Country:US
Mailing Address - Phone:801-380-3914
Mailing Address - Fax:
Practice Address - Street 1:1003 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5601
Practice Address - Country:US
Practice Address - Phone:801-380-3914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5935490-3503104100000X
UT5935490-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker