Provider Demographics
NPI:1114769684
Name:PHELPS, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7739 SW CAPITOL HWY STE 260
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2571
Mailing Address - Country:US
Mailing Address - Phone:971-236-2486
Mailing Address - Fax:
Practice Address - Street 1:7739 SW CAPITOL HWY STE 260
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2571
Practice Address - Country:US
Practice Address - Phone:971-236-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9263106H00000X
ORR9259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist