Provider Demographics
NPI:1477677664
Name:ENNS, CARISSA DEE (DPT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:DEE
Last Name:ENNS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76140 ROAD 423
Mailing Address - Street 2:
Mailing Address - City:COZAD
Mailing Address - State:NE
Mailing Address - Zip Code:69130-5211
Mailing Address - Country:US
Mailing Address - Phone:308-325-7302
Mailing Address - Fax:
Practice Address - Street 1:303 E 12TH ST
Practice Address - Street 2:
Practice Address - City:COZAD
Practice Address - State:NE
Practice Address - Zip Code:69130-1506
Practice Address - Country:US
Practice Address - Phone:308-784-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2500225100000X
WY1093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist