Provider Demographics
NPI:1073113932
Name:ENNIS, CHARLENE NICOLE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:NICOLE
Last Name:ENNIS
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 1:3285 FERGUSON ST. SW
Mailing Address - Street 2:
Mailing Address - City:TUNWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512
Mailing Address - Country:US
Mailing Address - Phone:360-252-2989
Mailing Address - Fax:
Practice Address - Street 1:3285 FERGUSON ST. SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-252-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health