Provider Demographics
NPI:1093857351
Name:ENOCKSON, DOROTHY CARMELITE SR (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:CARMELITE
Last Name:ENOCKSON
Suffix:SR
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:DOROTY
Other - Middle Name:
Other - Last Name:ENOCKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4901 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2622
Mailing Address - Country:US
Mailing Address - Phone:651-426-6374
Mailing Address - Fax:
Practice Address - Street 1:4901 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2622
Practice Address - Country:US
Practice Address - Phone:651-426-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical