Provider Demographics
NPI:1700660958
Name:MACKENZIE, ADAM J (PHD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:J
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 E RIVERPARK LN STE 220
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6559
Mailing Address - Country:US
Mailing Address - Phone:208-344-2071
Mailing Address - Fax:208-344-2075
Practice Address - Street 1:671 E RIVERPARK LN STE 220
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6559
Practice Address - Country:US
Practice Address - Phone:208-344-2071
Practice Address - Fax:208-344-2075
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1171360103TC1900X
ND642103TC0700X
ND642P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist