Provider Demographics
NPI:1003909730
Name:ENNIS, KAY E (PHD)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:E
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 NIEVE LN
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-4352
Mailing Address - Country:US
Mailing Address - Phone:575-640-7022
Mailing Address - Fax:
Practice Address - Street 1:2800 NIEVE LN
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-4352
Practice Address - Country:US
Practice Address - Phone:575-640-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1034103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600035OtherVALUE OPTIONS