Provider Demographics
NPI:1457506305
Name:ENNIS, PATRICK S (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:S
Last Name:ENNIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 10TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5291
Mailing Address - Country:US
Mailing Address - Phone:707-523-6939
Mailing Address - Fax:
Practice Address - Street 1:320 10TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5291
Practice Address - Country:US
Practice Address - Phone:707-523-6939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS182081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical