Provider Demographics
NPI:1194849083
Name:ENNIS, DONALD L (PH D)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:ENNIS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 496763
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75049-6763
Mailing Address - Country:US
Mailing Address - Phone:469-450-5539
Mailing Address - Fax:
Practice Address - Street 1:514 FAIRWAY LAKES DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-5043
Practice Address - Country:US
Practice Address - Phone:469-450-5539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00F89COtherBLUE CROSS
TX00F89CMedicare PIN
TXR78335Medicare UPIN