Provider Demographics
NPI:1609538024
Name:ENNIS, TAMMY MAE
Entity Type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:MAE
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 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2168
Mailing Address - Country:US
Mailing Address - Phone:860-378-8162
Mailing Address - Fax:
Practice Address - Street 1:AMERICAN SCHOOL FOR THE DEAF
Practice Address - Street 2:139 NORTH MAIN STREET
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-956-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT85755341401041S0200X
CT26481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool