Provider Demographics
NPI:1366028219
Name:ENNIS, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908A W CHANDLER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-4903
Mailing Address - Country:US
Mailing Address - Phone:480-899-0200
Mailing Address - Fax:
Practice Address - Street 1:908A W CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-4903
Practice Address - Country:US
Practice Address - Phone:480-899-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)