Basic Information
| Provider Information | |||||||||
| NPI: | 1043434194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, NCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACKEY | ||||||||
| OtherFirstName: | JIM | ||||||||
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| OtherCredential: | LPC, NCC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | 7195726089 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 S PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2991 | CO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC.0002991 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 89478843 | 05 | CO | MEDICAID |