Provider Demographics
NPI:1285844936
Name:ENNIS, MICHAEL (OTR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ENNIS
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:MA
Mailing Address - Zip Code:02343-1012
Mailing Address - Country:US
Mailing Address - Phone:781-961-3994
Mailing Address - Fax:
Practice Address - Street 1:164 PARKINGWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5020
Practice Address - Country:US
Practice Address - Phone:617-773-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5229225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist