Provider Demographics
NPI:1699017723
Name:ENNIS, TRACY (MS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 DIXON RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2133
Mailing Address - Country:US
Mailing Address - Phone:518-798-2088
Mailing Address - Fax:518-798-2088
Practice Address - Street 1:123 DIXON RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-2133
Practice Address - Country:US
Practice Address - Phone:518-798-2088
Practice Address - Fax:518-798-2088
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor