Provider Demographics
NPI:1578609814
Name:ENNEIS, ELIZABETH SHAND (MFT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:SHAND
Last Name:ENNEIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:SHAND
Other - Last Name:ENNEIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:1151 DOVE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2805
Mailing Address - Country:US
Mailing Address - Phone:949-374-2321
Mailing Address - Fax:949-481-3680
Practice Address - Street 1:1151 DOVE ST STE 105
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2805
Practice Address - Country:US
Practice Address - Phone:949-374-2321
Practice Address - Fax:949-481-3680
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30245106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist