Provider Demographics
NPI:1225442239
Name:ENIS, TABATHA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TABATHA
Middle Name:
Last Name:ENIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 OLD HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-1111
Mailing Address - Country:US
Mailing Address - Phone:662-760-2405
Mailing Address - Fax:
Practice Address - Street 1:399 OLD HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-1111
Practice Address - Country:US
Practice Address - Phone:662-760-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC28581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical