Provider Demographics
NPI:1659651370
Name:MACKELVIE, IAN DOUGLAS (LCSW)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:DOUGLAS
Last Name:MACKELVIE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-0232
Mailing Address - Country:US
Mailing Address - Phone:707-440-9288
Mailing Address - Fax:
Practice Address - Street 1:1302 11TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2029
Practice Address - Country:US
Practice Address - Phone:074-409-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62012101Y00000X
171M00000X, 390200000X
CA847961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program