Provider Demographics
NPI:1164595443
Name:ENNELS, GEORGE M (LCSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:ENNELS
Suffix:
Gender:M
Credentials:LCSW
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Other - Credentials:
Mailing Address - Street 1:224 GREAT BRIDGE BLVD
Mailing Address - Street 2:CITY OF CHESAPEAKE TA CHESAPEAKE COMM. SERV. BOARD
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3904
Mailing Address - Country:US
Mailing Address - Phone:757-547-9334
Mailing Address - Fax:757-819-6292
Practice Address - Street 1:224 GREAT BRIDGE BLVD
Practice Address - Street 2:CITY OF CHESAPEAKE TA CHESAPEAKE COMM. SERV. BOARD
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3904
Practice Address - Country:US
Practice Address - Phone:757-547-9334
Practice Address - Fax:757-819-6292
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA09040009801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA088100OtherTRIGON
VA325673OtherMAMSI
VA325673OtherMAMSI