Provider Demographics
NPI:1568929404
Name:ENNIS, VERONICA (OTD, OTR)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:
Other - Last Name:BUIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:951-335-9825
Mailing Address - Fax:812-590-8333
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 112
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7243
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:760-771-9057
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25919225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist